Nodaway Healthcare

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Base on observation, interview, and record review the facility failed to ensure that residents who are unable to carry out activities of daily living received the necessary services to maintain good, grooming, personal hygiene, when the facility failed to provide proper peri care for four of the 12 sampled residents, (Resident #3, #12 and #28), and when the facility failed to provide proper catheter care for resident #16. The facility census was 30. Review of facility Perineal Care policy, dated February 2018, showed: -For a female resident wash perineal area, wiping from front to back, separate labia and wash area downward from front to back; -If the resident has an indwelling catheter, gently was the juncture of the tubing from the urethra down the catheter about three inches. Gently rinse and dry the area; -For a male resident wash perineal area starting with urethra and working outward. 1.Review of Resident #28's Care Plan dated 06/26/2025 showed: -Resident was limited physical mobility related 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 record review, the facility failed provide proper respiratory care when staff failed to date the oxygen tubing for two residents (Resident #7 and #30), failed to clean the oxygen concentrator filters for one resident (Resident #7), failed to have an oxygen filter installed for one resident (Resident #5), and failed to obtain an order for oxygen prior to administering to a resident (Resident #30). This affected three of 12 sampled residents. The facility census was 30. Review of the facility's Oxygen Administration policy, revised October 2010, showed:- Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration;- Review the resident's care plan to assess for any special needs of the resident;- Equipment and supplies: Portable oxygen cylinder strapped to the stand, nasal cannula, nasal catheter, mask (as ordered), humidifier bottle, No Smoking/Oxygen in Use signs, regulator, and PPE as needed;- Check…

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 observations, interviews and record review, the failed to ensure staff discarded expired medications and biologicals stored in the medication room and in the nurse's medication cart. The facility census was 30. Review of the facility's undated policy for Storage of Medications, showed:- The facility shall store all drugs and biologicals in a safe, secure, and orderly manner;- Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers;- Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing;- The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. 1. Observation and interview on 8/5/25 at 2:37 P.M., of the medication room showed:- One opened vial of Tuberculin, purified protein derivative,0.1 ml., dated 6/13/25. The label on the box…

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, record review, and interviews, the facility failed to store, prepare and serve food in accordance with professional standards of food service safety when staff failed to discard expired leftovers in the refrigerator, failed to maintain proper standards of cleanliness and storage in the kitchen area, and failed to use proper handwashing hygiene in the kitchen. This affected all residents by putting them at risk for a food borne illness. The facility census was 30.Review of facility policy Bare Hand Contact with Food and Use of Plastic Gloves, undated, showed:- Single-use gloves will be worn when handling food directly with hands to assure that bacteria are not transferred from the food handler' hands to the food product being served;- Hands are to be washed when entering the kitchen and before putting on the single-use gloves and after removing single use gloves;- Anytime a contaminated surface is touched, the gloves must be changed, and hands must be washed;Review of facility policy Food Receiving and Storage, revised July 2014, showed:- Food services, or other…

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 submit the Payroll Based Journal (PBJ) data (a mandatory submission by nursing facilities to the Centers for Medicare & Medicaid Services detailing facility staffing levels, including staff identification, hours worked, and job titles, on a quarterly basis correctly for Quarter 2 2025 (January 1 to March 31). The facility census was 30 The facility did not provide a policy for PBJ. Review of the facility's Payroll Based Journal data (PBJ - a report that provides staffing data set information submitted by nursing homes on a quarterly basis) for Quarter 2 2025 (January 1 - March 31) showed no RN coverage hours on 2/23, 3/2, 3/16, 3/29, and 3/ 30 and no licensed nurse on 1/25, 2/11, 3/13 and 3/29. Review of staffing schedule for February 2025 showed no RN on the day: 2/23. Review of the staffing schedules for March 2025 showed no RN on the following days: 3/2, 3/16, 3/29 and 3/30.During an interview on 8/5/25 at 9:52 A.M., the Regional Nurse said:- He/She knew something was not right with the PBJ and did not think it had been…

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 interviews and record review, the facility failed to follow care plan directions for maintaining and using hearing aids for one resident of 12 sampled (Resident #30). The facility census was 30. Review of facility policy Care Plans, Comprehensive Person-Centered, revised September 2013, showed the care plan will include measurable objectives and timeframes and describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being;Review of facility policy Activities of Daily Living (ADL), Supporting, revised March 2018, showed:- Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry ot activities of daily living (ADLs);- Appropriate care and services will be provided for residents including appropriate support and assistance with communication (speech, language, and any functional communication systems;1. Review of Resident #30's Quarterly MDS dated [DATE],…

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 observations, interviews and record review, the facility failed to provide an environment free from accident hazards when staff did not implement new interventions to prevent falls for one of the 12 sampled residents, (Resident #3), who was at risk for falls and who had experienced multiple falls and failed to update the resident's fall risk assessment with each new fall. The facility census was 30. 1. Review of Resident #3's medical record showed the resident was admitted on [DATE] at 12:15 P.M. Review of the resident's progress notes showed:- 5/24/25 at 12:30 P.M., the resident was found on the right side of the bed on the floor. No injury noted;- 5/25/25 at 1:15 P.m., the resident had an unwitnessed fall. The resident was found on the floor, no injury noted. Review of the resident's fall risk assessment, dated 5/25/25 showed the resident scored 20 (indicated the resident was at risk for falls). Review of the resident's progress notes showed:- 5/27/25 at 6:50 A.M., a Certified Nurse Aide (CNA) noticed…

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 pain management was provided for one resident, (Resident #1) when staff failed to obtain any medications for the resident for the first 48 hrs after admission from an acute hospital stay following a vehicle accident. The facility census was 39. Review of facility policy, protocol for pain management and as needed medication, undated, showed: -Pain management must be provided to a resident who requires such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences; -Nurses will complete a pain evaluation on each resident for pain upon admission to the facility every week for four weeks, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. -The nurses will either use the FACES pain rating scale (for non-verbal or cognitively impaired residents or residents that do not speak English) or the 10 point pain intensity scale. -Nursing staff 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.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure nebulizer tubing and a nebulizer mouthpiece were cleaned after use and stored in a manner to prevent potential contamination between uses for 1 (Resident #22) of 1 resident reviewed for respiratory care. Findings included: A facility policy titled, Departmental (Respiratory Therapy)- Prevention of Infection, revised 11/2011, specified, The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. The section of the policy addressing, Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol indicated, 3. After completion of therapy: a. Remove the nebulizer container; b. Rinse the container with fresh tap water; and c. Dry on a clean paper towel or gauze sponge. 4. Reconnect to the administration set-up when air dried. 5. Take care not to contaminate internal nebulizer tubes. 6. Wipe the mouthpiece with damp paper towel or gauze sponge. 7.…

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 provide personal funds and a final accounting within thirty days upon discharge. This affected two of five sampled residents (Resident #1 and #2) Facility census was 38. Review of facility policy, Conveyance upon discharge, eviction, or death policy, dated 2019, showed: -Upon discharge, eviction, or death of a resident with a personal fund deposited with the facility, the facility shall convey within 30 days the resident's funds and final accounting of those funds, to the resident, his or her legal representative, or in the case of death, the individual, or probate jurisdiction administering the resident's estate, in accordance with state law. 1. Review of the facility's interim aging report, dated 8/21/24, showed the following residents had money in the facility's operating account: -Resident #1 discharged on 2/1/24, with a balance of $2,428.00; -Resident #2 discharged on 7/9/24, with a balance of $5,531.46. Review of Request for Resident Refund invoices showed: -On 7/16/24, Business Office Manager (BOM) submitted invoice…

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 record review and interviews, the facility failed to ensure they used the services of a registered nurse (RN) for at least eight consecutive hours a day on the day shift, seven days a week. This had the potential to affect all residents who resided in the facility. The facility's census was 30. Review of the facility's undated policy regarding RN coverage showed the requirements for long term care facilities require that a skilled nursing facility provide 24-hour nursing services, an RN for eight consecutive hours a day, seven days a week (more than 40 hours a week), and that there be an RN designated as Director of Nursing (DON) on a full time basis. Review of the facility's December 2021 schedule sheets, which showed all nursing staff scheduled for the entire month of December, showed: - 12/8/21, 12/9/21, 12/21/21, 12/22/21, and 12/28/21 they only had an RN scheduled 4 hours during the day, from 2:00 P.M. to 6:00 P.M.; - On 12/15/21, they only had an RN scheduled 3 hours during the day, 3:00 P.M. to 6:00 P.M.; - On 12/14/21, and 12/27/21 the facility did not have an RN…

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, record review and interviews, the facility failed to ensure they provided each resident with a nourishing, palatable, well-balanced diet to meet their daily nutritional and special dietary needs when staff failed to ensure they covered foods when transporting them from the kitchen to resident rooms and prepared the meals too far in advance. This affected all residents who received their meals from the facility's kitchen. The facility census was 30. The facility did not provide any dietary policies regarding covering foods during transport of when to prepare the meals. 1. Observation and interview on 3/16/22 at 10:26 A.M., the dietary manager (DM) said she already had to noon meal prepared and on the steam table. The evening cook would be starting his/her meal prepare around 3:00 P.M. Observation of the noon meal on 3/16/22 showed staff served the residents' choice meal for the noon meal, chili and a baked potatoes. The bake potatoes appeared to have shriveled from sitting on the steam table for too long. Observation and interview on 3/16/22 at 3:20 P.M. showed…

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, record review and interviews, the facility failed to ensure they stored, prepared, and distributed foods in accordance with professional standards of food service safety when staff did not date foods when opened, did not change gloves and wash their hands when moving from one task to another, and failed to keep all surfaces clean, all of which affected all residents who received food from the facility's kitchen. The census was 30. The facility did not provide any cleaning schedules. The facility did not provide a policy on hand washing and glove changes in the kitchen. The facility did not provide a policy to address dating foods when opened. 1. Observation on 3/14/22 at 10:20 A.M., during the initial tour of the kitchen showed: - The walking refrigerator: black cherry drink not dated, opened, two individual condiment cups not dated, ham slices in zip lock bag not dated and on top of defrosting vegetable soup; - The ultra skillet handles were greasy and sticky with thick black substance; - The controls on oven with thick black greasy residue; - The smoke…

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 follow their set Antibiotic Stewardship Program (ASP) when they failed to maintain appropriate antibiotic tracking and use of the standard assessment and communication tool-SBAR for 3 residents (Resident #22, #24 and #27) out of 17 sampled residents. This had the potential to effect all residents. Facility census was 30. Review of facility policy Antibiotic Stewardship Program dated September 2017 showed in part: -The facility will use a standard assessment and communication tool for residents suspected of having an infection-SBAR. -Monitor both antibiotic use practices and outcomes related to antibiotics in order to guide practice changes and track the impact of changes. -The Infection Preventionist will be responsible for the ASP in the faciltiy i.e.: -Tracks antibiotic starts, resistance patterns, and/or increased usage rates. -Tracks the number of adverse events. - Monitor SBAR forms for completion 1. Record review of Resident #22 medical records showed: -Order for Macrobid (a prescription medication used to treat…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure they did not hold residents' monies separate from facility money when they did not reimburse residents and/or their responsible parties after the residents were discharged , which affected six residents sampled for resident trust fund (RTF) review (Residents #30, #31, #32, #33, #34 and #80). The facility's census was 30. Review of the Personal Funds Agreement, dated 2016, showed: - The facility offers the service of holding and managing residents' personal funds. Residents are not required, however to deposit their personal funds with us. They may manage their own funds or have a family member or other person do so. - I understand that within five (5) days of my discharge from the facility, an up to date accounting and the balance of my personal funds will be given to me, my guardian/conservator or any other person I designate in writing. - I understand that if I die with money in my personal funds account if I have received any Medicaid…

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 record review and interviews, the facility failed to ensure they maintained a surety bond in an amount to cover any loss of theft to residents' money held in the facility's Resident Trust Fund (RTF) account which affected all residents who had money held in their RTF account. The facility's census was 30. Review of the facility's approved surety bond, approved 7/29/20, showed an approved amount of $15,000.00. Review of the RTF worksheet, completed with the Business Office Manager, on 3/21/22, showed: - The average monthly balance for the facility's interest bearing account and petty cash account of $12,580.84; - The approved bond amount for this average monthly balance (Grand Total rounded to the nearest thousand x 1.5 = required bond amount) should be at least $18, 871.50; $3871.50 more than the approved amount. During an interview on 3/21/22 at 2:13 P.M., the Business Office Manager said she completed the form and found they had the correct amount, but did not use the appropriate amount when figuring the ending balance for the petty cash account each month. The 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 observation, record review and interviews, the facility failed to ensure they developed person-centered, complete, accurate and individualized care plans based on residents' comprehensive care plans to address the specific needs of the residents which affected for five of 12 sampled residents (Residents #1, #4, #13, #22, and #27). The census was 30. The facility did not provide a policy for developing, implementing or updating residents' plans of care. 1. Review of Resident #13's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/24/21, showed: - A Brief Interview for Mental Status (BIMS) score of 6, indicating moderate cognitive impairment; - Scored a 1 on the mood interview, meaning the resident is not at risk for depression; - Independent with bed mobility, moving on the nursing unit, eating; supervision with personal hygiene, toilet use, moving off the nursing unit, and walking in the corridor; limited assistance with dressing; - Diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities designed to meet the resident's interests for three of 12 sampled residents. (Resident #27, #4, #22). The facility census was 30. Review of facility policy for Providing Activities, dated January 2019, showed: -It is the policy of the facility to provide an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests, and the physical, mental and psycho-social well-being of the residents. -The facility identifies each resident's interests and needs and involves the resident in an ongoing program of activities that is designed to appeal to his or her interests, and to enhance the resident's highest practicable level of physical, mental and psycho-social well-being. 1. Review of Resident # 27 Quarterly Minimum Date Set (MDS), a federally mandated assessment instrument completed by staff, dated 2/18/22 showed: -BIMS of 1, unable to make decisions…

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

Based on observation, record review and interviews, the facility failed to ensure they conducted assessments for risk of entrapment from bed rails prior to installation and failed to review the risks and benefits of bed rails with the resident and their representative and obtain informed consent prior to installation. This had the potential to affected all facility residents, and affected one of 12 sampled residents (Resident #25). The facility census was 30. The facility did not provide a policy on bed rails. 1. Review of Resident #25's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, date 2/4/22, showed: - A Brief Interview for Mental Status (BIMS) score of three which indicated severe cognitive impairment; - Independent with bed mobility, transfers; not steady when moving from a seated to standing position or moving from surface to surface, but steady with human assistance; - Diagnoses included unspecified sequelae of cerebral infarction (residual effects or conditions produced after the acute phase of an illness or injury…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that a dementia care plan was developed for four sampled residents (Residents #14, #4, #22, and #27) with dementia diagnosis out of 12 sampled residents. The facility census was 30. The facility did not provide a policy to address behaviors or handling residents with dementia.1. Record review of Resident #14's admission Face Sheet showed he/she was admitted to the facility on [DATE] with the diagnosis of Dementia with behavioral disturbances. Record review of the resident's significant change Minimum Data Set (MDS) a federally mandated assessment instrument completed by the facility staff for care planning dated 12/31/21 showed : -His/her BIMS (brief interview for mental status) score of 0 ( indicating morbid cognitive impairment) -Had an active diagnosis of Dementia; -He/she exhibited no behaviors; -He/she needed extensive assistance to dependence with Activities of Daily Living. (ADLs) Record review of the resident's Comprehensive Care Plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure they provided a notice before transfer and/or discharge for one of 12 sampled residents (Resident #2) when they transferred the resident to the hospital. The facility census was 30. Review of the undated Facility Initiated Transfer or Discharge of Resident policy, showed on occasion, residents may be transferred or discharged for various reasons and these transfers and discharges may be initiated by the facility. The facility may initiate transfer or discharge for the following reasons including the transfer or discharge is necessary to meet the resident's welfare and the resident's welfare cannot be met in the facility. The procedure included: - Should the facility determine that transfer/discharge is necessary, the facility shall complete the following: *Resident, family and/or legal representative will be given 30 day notice prior to transfer or discharge when a resident's urgent medical needs require more immediate transfer; - The policy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure they provided a notice of their bed-hold policy before transferring for one of 12 sampled residents (Resident #2) when they transferred the resident to the hospital. The facility census was 30. Review of the facility's September 2017 Bed Hold/readmission Policy showed to comply with Federal rules, this facility is giving the letter to you and/or your resident representative at this time to inform you of the policy on bed holds and readmission to our facility. Residents and the resident representative will be sent a letter each time one of the following events take place: - Resident is transferred to the hospital; - Resident goes on a therapeutic visit; - Facility determines that a resident, who was transferred with an expectation of returning to the facility, cannot return and the facility shall initiate the notice of discharge. Review of Resident #2's significant change in condition Minimum Data Set (MDS), a federally mandated assessment…

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, record review and interviews, the facility failed to ensure they completed an accurate comprehensive assessment which reflected residents' status for one of 12 sampled residents (Resident #25). The facility census was 30. The facility did not provide a policy on completing the Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, for residents. Review of Resident #25's annual MDS, dated [DATE], showed: - A Brief Interview for Mental Status (BIMS) score of 5, indicating moderate cognitive impairment; - No behaviors, such as physical or verbal behavioral symptoms directed towards others, did not reject care, and no change in current behavior status. - Independent with all activities of daily living (ADLs); - Always continent of bowel and bladder; - No falls since prior assessment.; - No ulcers, wounds and skin problems. Review of the resident's behavior flow sheet showed staff documented the following: - The resident was agitated 19 times between…

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 closed record review , the facility failed to ensure staff completed a comprehensive discharge summary for one of the two sampled closed records (Resident #9) to include appropriate information about the resident's diagnosis, course of illness/treatment or therapy, a post discharge plan of care to assist the resident to adjust to his/her new living environment when applicable. The facility census was 30. Review of facility policy titled Discharge Planning Policy, undated, showed the following: -To complete discharge planning on any resident where discharge is anticipated to home, another skilled nurse facility/nursing facility or other type post acute setting. -Discharge planning is a patient centered, interdisciplinary process that begins with an initial assessment of the residents potential needs at the time of admission and continues throughout the resident's stay. -Resident's and representatives should be informed of the appropriate community resources available and encouraged 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.

Based on observations, record review and interviews, the facility failed to follow safety standards and policy for one of 12 sampled residents (Resident #1) who had no smoking assessment. Facility census was 30. Review of facility policy Smoking Policy dated October 2017 showed in part: -Any resident who smokes shall be assessed for their ability to smoke safely unsupervised. Assessments shall be conducted upon admission, quarterly and with changes in condition. -The assessment shall include cognition, communication/vision/hearing, physical abilities, safety risk history, and observations of smoking history. 1. Review of Resident #1 quarterly Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff) dated 3/8/22 showed: -Brief Interview of Mental Status (BIMS) of 5. (this indicates moderate to severe cognitive impairment). -Diagnosis of Alzheimer's Dementia and Dementia with Behavioral Disturbance. -Needs supervision of staff with dressing and hygiene. Review of the resident's Care Plan dated 11/26/21 showed -Cognitive Defect: break things down into…

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 record review and interviews, the facility failed to ensure residents remained free from unnecessary drugs when staff failed to discontinue the use of as needed (PRN) opioids after 14 days or have the physician reassess the appropriateness of the continued use of the medication for one of 12 sampled residents (Resident #2). The facility census was 30. The facility did not provide a policy to address the use of unnecessary drugs and discontinuing PRN opioids after 14 days. 1. Review of Resident #2's significant change in condition Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 12/3/21 , showed: - Long and short-term memory problems; - Extensive staff assistance with bed mobility, transferring from one surface to another, dressing, toilet use and personal hygiene; - Diagnoses included: Alzheimer's disease, - Not on scheduled pain medication, PRN medication and not received any non-medication interventions for pain; no presence of pain; - Had not received any opioids in the previous seven days; - Hospice. Review 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.

Based on record review and interviews, the facility failed to ensure residents remained free from unnecessary drugs when staff failed to discontinue the use of as needed (PRN) psychotropic medications after 14 days or have the physician reassess the appropriateness of the continued use of the medication and failed to ensure they attempted an gradual dose reduction (GDR) in an effort to discontinue psychotropic drug use, unless clinically contraindicated for one of 12 sampled residents (Resident #2). The facility census was 30. The facility did not provide a policy to address the use of unnecessary drugs, gradual dose reductions and discontinuing PRN opioids after 14 days. 1. Review of Resident #2's significant change in condition Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 12/3/21 , showed: - Long and short-term memory problems; - Extensive staff assistance with bed mobility, transferring from one surface to another, dressing, toilet use and personal hygiene; - Diagnoses included: Alzheimer's disease; - Exhibited behavior symptoms…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to collaborate with hospice in the development of a coordinated plan of care for residents receiving hospice care. This affected two of 12 sampled residents. (Resident #2 and #22). The facility census was 30. Review of the undated Comparison of Facility/Hospice Responsibilities, part of the facility's contracted agreement with hospice providers showed: - Hospice plan of care (HPOC) must identify the care and services that are needed and specifically identify which provider is responsible for performing the respective functions that have ben agreed upon and included in the HPOC. - HPOC reflects participation by the hospice, facility, patient and patient's family. - Discussions of changes to the HPOC with the facility or patient; - Approval by Hospice of any changes to the HPOC prior to implementation. 1. 1. Review of Resident #2's significant change in condition Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated…

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

Based on observation, interview, and record review, the facility failed to ensure staff who are not up-to-date with COVID-19 vaccination were routinely tested for COVID-19 according to their policy and county transmission rate. This affected four staff members and had the potential to affect all residents. The facility census was 28. 1. Review of the facility's policy titled COVID-19 Vaccination Policy, dated 2/2022, showed the following: - Purpose- In accordance with the facility's duty to provide and maintain a workplace that is free of known hazards, the facility was adopting the policy to safeguard the health of the employees and their families, customers and visitors and the community at large from the COVID-19 virus, that may be reduced by vaccinations. This policy will comply with all applicable laws and is based on guidance from the Centers for Disease Control and Prevention (CDC), Centers of Medicare and Medicaid Services (CMS), and local Health authorities; - Scope- All employees are required to receive the COVID-19 vaccination as determined by CMS, unless a reasonable…

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 record review, the facility failed to fully develop and implement their staff vaccination policy for COVID-19 when they did not ensure all required components were included in the policy and failed to implement a process for tracking and documenting the COVID-19 vaccination status for all staff. Facility census was 30. 1. Review of the facility's policy titled COVID-19 Vaccination Policy, dated 2/2022, showed the following: - Purpose- In accordance with the facility's duty to provide and maintain a workplace that is free of known hazards, the facility was adopting the policy to safeguard the health of the employees and their families, customers and visitors and the community at large from the COVID-19 virus, that may be reduced by vaccinations. This policy will comply with all applicable laws and is based on guidance from the Centers for Disease Control and Prevention (CDC), Centers of Medicare and Medicaid Services (CMS), and local Health authorities; - Scope- All employees are required to receive the COVID-19 vaccination as determined by CMS,…

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

Based on observation and interview, the facility failed to ensure the corridor was equipped with firmly secured handrails and handrails are in good repair on one side of the hall. The facility census was 30. Observations on 3/14/22 at 2:20 P.M. showed: - On the 200 hall, first handrail at central bath was loose. - The handrail by the soiled utility room is loose and cracked with jagged edges. During an interview on 3/21/22 at 2:05 P.M. the Maintenance Director said: - He/she does not do rounds and check handrails. - He/she was unaware some needed repaired; - Handrails should not be jagged or loose since the residents use those to stabilize when walking down the halls During an interview on 3/21/22 at 4:19 P.M., the Administrator said handrails should be checked and maintained in good condition.