St John's Lutheran Home

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive, person-centered care plan, for a resident who required oxygen therapy for 1 (#12) of 25 sampled residents. The facility's failure could jeopardize the resident's health resulting in a risk for low blood oxygen levels or oxygen services not being provided. Findings include:During an observation on 7/16/25 at 10:36 a.m., resident #12 was in her room sitting in a recliner with her legs elevated. Resident #12 appeared to be asleep with a nasal cannula applied to her nostrils. Resident #12's oxygen concentrator was running at 2 liters per minute. During an interview on 7/17/25 at 9:37 a.m., staff member B stated the MDS nurse and interdisciplinary team were responsible for updating a resident's care plan. Staff member B stated he was not sure why resident #12's oxygen therapy was not initiated in the resident's care plan. Staff member B stated, I don't know why it is not there. Review of resident #12's medical provider order, dated 2/20/25 at 9:30 a.m., showed, Oxygen at 2…

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 a resident-centered care plan was updated to include specific activity preferences and current participation for 2 (#s 24 and 56); and include use of enhanced barrier precautions for 1 with an indwelling urinary catheter (#9) of 25 sampled residents. This deficient practice increased the risk of staff members not implementing resident-centered care plans in the specific areas of activities and infection control. Findings include: 1. During an observation and interview, on 7/14/25 at 3:45 p.m., resident #32 was sitting in her recliner with her feet elevated, watching television. When asked, resident #32 stated she did participate in activities, but she was unable to identify which activities she participated in. Resident #32 was able to answer yes or no questions regarding participation in reading activities and watching television. The resident was unable to recite or recall the names of any activities on her own. NF1 arrived at 3:50 p.m. and joined the conversation regarding resident #32's care. NF1…

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 the medication error rate was less than five percent, for 2 (#s 35 and 77) of 25 sampled residents. The medication error rate was calculated as 5.41 percent, and the medication errors placed the residents at increased risk of negative outcomes. Findings include:During a medication administration observation and interview on 7/15/25, between 8:28 a.m. and 8:45 a.m., staff member N stated, “I got busy in the other cottage, and [resident #77] was already wheeled out to the dining room, so I will just wait until she finishes her breakfast and returns to her room to give her insulin. Staff member N administered resident #77's insulin dose at 8:42 a.m., after resident #77 completed her breakfast and returned to her room. Review of resident #77's physician order, dated 7/4/25, showed, “Humalog 100 unit/ml Kwikpen before meals and at bedtime .” During an observation and interview on 7/16/25 at 8:04 a.m., staff member J gave two 500 mg tablets of acetaminophen to resident #35, who had been eating breakfast. In…

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

Based on interview and record review, the facility failed to report their investigative findings of a facility reported incident to the State Survey Agency in a timely manner for 2 (#s 23 and 72); and failed to report allegations of resident abuse to the State Survey Agency within 24 hours of the incident for 2 (#s 24 and 95) of 25 sampled residents. This deficient practice increased the risk of unnecessary psychosocial harm to the residents involved in the incident due to the delay in reporting both the allegations of resident abuse and results of the facility investigation. Findings include: 1. Review of a facility-reported incident, dated 4/30/25, showed resident #23 and resident #72 were involved in an exchange at a cottage dining room. Resident #72 was witnessed by staff yelling at and insulting resident #23. Review of the facility reported incident findings, submitted 5/9/25, showed both residents (#23 and #72) were attended to and evaluated by staff members. Resident #72 was assessed by a provider to obtain behavioral health treatment following the incident. Staff members…

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 interview, the facility failed to ensure residents were served meals to meet their nutritional needs, and staff serving meals failed to use the menu's and serve the planned meal, or offer an appropriate substitute, for the residents in the [NAME] Cottage. Findings include. During observations on 8/13/24 from 8:39 to 8:58 a.m., in the [NAME] cottage, staff member N did not review the residents diet orders or the menu prior to meal service. Staff member N did not use the required scoop size when serving the protein. Staff member N did not use a scoop when serving the bacon. Staff member N used her hand to scoop bacon out of the robo coupe. Five residents had orders for minced and moist diet. Staff member N scooped a serving of bacon out of the robo coupe with her hands for all five residents. The menu stated banana french toast was to be served for breakfast. The residents were served regular toast or pancakes. The residents were not asked their preferences prior to being…

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 update the comprehensive care plan for a resident who was dealing with grief, for 1 (#41); failed to update the care plan of a resident with frequent falls for 1 (#47); and failed to update the care plan of a resident who no longer had adjustment issues for a room change which occurred more than 12 months prior for 1 (#3) of 26 sampled residents. Findings include: 1. During an interview on [DATE] at 3:07 p.m., resident #41 said he was having problems dealing with some confusion and issues in his life. Resident #41 said his wife died in October of last year, and he still missed her. Resident #41 said his family visited, but he still missed his wife and expected to see her in her room at the cottage where they lived. He said someone from the facility may have talked to him at one time. Review of resident #41's current care plan failed to show a focus area related to grief due to the death of the resident's wife. No interventions were in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to post daily staffing in the four cottages which housed 51 longterm care residents. Failing to post the daily staffing would not allow anyone wishing to view the informaton, such as residents, staff, or visitors. Findings include: During multiple observations during the survey, which occurred from 8/12/24 to 8/15/24, no nurse staff posting was found in any of the four cottages. During an interview on 8/14/24 at 8:17 a.m., staff member H was not able to identify where the nurse staffing was posted in [NAME] and [NAME] Cottages. Staff member H stated she knew there was staffing posted on the rehabilitation unit, but did not remember seeing any postings in the cottages. During an interview on 8/15/24 at 11:55 a.m., staff member B was not aware there was no staff postings in the cottages.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the dietary department failed to provide each resident with a nourishing diet and failed to follow the resident's therapeutic diet to meet the resident's daily needs. These deficient practices increased the risk of the [NAME] Cottage residents having negative nutritional or health outcomes, and affect their quality of life. Findings include: During observations on 8/13/24 at 8:39 a.m., staff member N was not reviewing diet orders and therapeutic menus to ensure proper diets and serving sizes were served when preparing residents meals. Staff member N ground some bacon in the robo coupe. With her gloved hands, she scooped out a handful of dry flakey bacon from the robo coupe bowl without measuring a portion. The practice of not measuring occurred when bacon was placed on five plates. Staff member N poured breakfast syrup on the bacon for residents who were to be served a minced and moist diet. During continued observation of breakfast service on 8/13/24 at 8:53…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure there were sufficient staff with the necessary competencies and skillsets to carry out the functions of the food and nutritive services. This deficient practice increased the risk of negative outcomes, and the quality of life and health, for the residents residing in the [NAME] and [NAME] Cottages. Findings include: During interview on 8/12/24 at 1:45 p.m. during the entrance conference, staff member A and staff member B said the cooks are shared between two cottages. The cook will complete meal prep in one cottage and then take the meal to the other cottage and serve the meal at the next cottage. Staff member A and B said the cooks have a buddy to help them with me meal service. During an observation on 8/14/24 at 8:47 a.m., the cook (staff member P) entered [NAME] Cottage and began preperation for meal service. The first two meals were served at 8:53 a.m. The posted meal time in the cottage was 8:00 a.m., or upon rising. The meal…

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, record review, and observations, the facility failed to provide each resident with food that accommodated the resident allergies and preferences for the residents in the [NAME] Cottage. Findings include: Review of the diet type report for the [NAME] Cottage showed a census of thirteen. Five of resident's/diets had physician orders to have a minced and moist texturally altered diet. Two other residents required specialized diets. One resident had a lactose restricted diet, and the other was a cardiac diet with no added salt. During observations on 8/13/24 from 8:39 to 8:58 a.m., in the [NAME] cottage, staff member N did not review the residents diet orders or the menu prior to meal service. The menu called for banana French toast. No French toast was served. The residents were not asked their preferences for meals. The minced bacon was served with syrup poured on top to make it moist. During an observation on 8/14/24 at 9:00 a.m., staff member P did not review the resident diet orders which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained in the kitchens. This deficient practice had the potential to affect all residents who received food from the kitchen in the Powers, [NAME], and [NAME] Cottages. Findings include: 1. During an observation and interview on 8/12/24 starting at 2:20 p.m., in the [NAME] Cottage, the following concerns were observed: - The floor in the kitchen area had a heavy accumulation of black colored film/matter along the edges of the baseboards, the door jambs, the dishwasher, the upright freezer, and the door thresholds. The film type matter in these areas could be scraped off with the tip of a pen or a finger nail. - In the pantry, behind the kitchen, there was a towel on the floor in front of the freezer door. Water was observed leaking from the freezer door. - The bottom of the freezer, under a drawer, had a half inch buildup of ice and two areas of brown rust colored stains. - Packages of unlabeled 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 observation and interview the facility failed to ensure infection contol practices were followed and the staff used appropriate PPE when the facility was in COVID-19 outbreak status. These deficient practices affected residents in the [NAME] Cottage (sanitary conditions) and the [NAME] Cottage (appropriate PPE). Findings include. 1. During an observation on 8/13/24 at 8:51 a.m., NF4 was observed with a stack of clean towels resting against her uniform. NF4 was carrying the uncovered towels down the hall. 2. During an observation on 8/13/24 at 10:01 a.m., NF4 was observed carrying dirty linen in her hands. She carried the uncovered linens past the clean linens and the dryers in the laundry room and placed the dirty linen on the floor near the washing machine. 3. During an observation on 8/14/24 at 9:32 a.m.,, staff member R was observed entering the [NAME] Cottage. Staff member R washed her hands and then turned the water faucet off with wet hands. Staff member R then dried her hands and began breakfast…

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 residents were assessed for the ability to self-administer medications prior to leaving a resident unattended while taking medications for 2 (#s 3 and 10) for 26 sampled residents. Findings include: During an observation on 8/13/24 at 9:16 a.m., staff member C left medications for resident #3 and #10, which were placed on the table in the dining room, at breakfast. After handing the medication cups to #3 and 10, with the medications in the cups, staff member C left the dining area and went to the nursing station to take a telephone call. There were no other nursing staff in the dining area who could have observed the resident taking their medications. During an interview on 8/13/24 at 9:20 a.m., staff member C stated she had planned to stay in the dining area until resident # 3 and 10 had finished taking their medications, but received a telephone call, and left the dining area to take the call. Staff member C stated she should not have left the residents unattended until they had both taken all of…

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 report an allegation of resident neglect within 24 hours of the incident, for 1 (#77) of 26 sampled residents for abuse reporting. Findings include: Review of a Facility Reported Incident submitted to the State Survey Agency, dated 8/1/24, showed there was an allegation of resident neglect by a staff member, towards resident #77. The report showed the incident occurred between 7/27/24 and 7/29/24. The facility investigation showed the allegation was reported to staff member J and staff member K via email on 7/30/24. The initial report of the incident was not submitted until 8/1/24, which was greater than 24 hours after the incident occurred. During an interview on 8/13/24 at 4:06 p.m., staff member B stated the staff member making the allegation was disgruntled and made the complaint as she was quitting her job after three days of employment. Staff member B submitted the abuse allegations to the state reporting portal when he found out about the allegation. Staff member B said the initial report to the incident portal was…

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

Based on interview and record review, the facility failed to accurately complete the Quarterly resident assessment for 1 (#3) of 26 sampled residents. Findings include: During an interview on 8/14/24 at 8:40 a.m., staff member D stated resident #3 did most of her personal care and hygiene on her own and usually refused to shower. Staff member D stated she gave the resident a choice between a shower and a sponge bath. This sometimes resulted in the resident accepting assistance with a shower. Staff member D stated she was assisting resident #3 with a shower on 7/27/24 and noticed her groin was very red. Staff member D stated she notified the nurse who examined the resident and recommended the use of nystatin powder or cream. Staff member D stated the resident refused to allow them to put anything on the resident's perineum. Review of resident #3's nursing note, dated 7/27/24, showed the nurse examined the resident and recommended several treatments. The note also showed the resident refused any of the recommended treatments. Review of resident #3's Quarterly MDS, with an ARD of…

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 develop and implement a baseline care plan to address resident care needs, for 2 (#s 78 and 143) of 26 sampled residents. Findings include: 1. Review of resident #78's EHR showed an admission date of 6/20/24. No baseline care plan, which was to be done within the first 48 hours, was located in the EHR for resident #78. A request was made for resident #78's baseline care plan on 8/15/24. No additional information was received by the end of the survey. During an interview on 8/15/24 at 10:00 a.m., staff member B stated a baseline care plan was not completed for resident #78. Staff member B stated the nursing staff could have forgotten to do the care plan because the resident was sent to the facility for a short end-of-life stay. The resident passed away six days after admission. Review of a facility policy, titled, Baseline Care Plan, date implemented January 2019, showed, Baseline Care Plans must be started within 48 hours of admission by IDT staff . 2. During an observation on 8/14/24 at 3:45 p.m., two CNA…

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 nursing staff failed to assess and document the condition of a resident's skin as part of preventative skin care, for 1 (#3) of 26 sampled residents. Findings include: During an interview on 8/14/24 at 8:40 a.m., staff member D stated resident #3 did most of her personal care and hygiene on her own. Staff member D stated she was assisting resident #3 with a shower on 7/27/24 and noticed her perineum was very red. Staff member D stated she notified the nurse who examined the resident and recommended either nystatin powder or the application of a barrier cream. Staff member D stated the resident refused any of the recommended treatments. Staff member D stated the CNAs monitor for skin problems during the resident's shower, and notify the nurse if anything abnormal is seen. Review of resident #3's EHR, dated from 1/1/24 to 8/14/24, failed to show the routine assessment of the condition of the resident's skin. Nursing progress notes, dated 1/8/24 and 1/9/24, showed the resident had a wound on the right side of her chin which was covered…

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

Based on observation, interview, and record review, the facility failed to sufficiently address repeated falls for a resident who had frequent falls, and staff failed to identify root causes for the repeated falls so they could attempt to prevent future falls, failed to evaluate the effectiveness of current interventions utilized at the time of a fall for potential modification related to the fall cause, and failed to show the care plan was used effectively and reviewed, updated, or modified for the ongoing falls, and prevention of future falls, for 1 (#47) of 26 sampled residents. The deficient practice continually increased the risk of injury and or ongoing falls. Findings include: During an observation and interview on 8/13/24 at 9:50 a.m., resident #47 was seated in a recliner in the day room with his walker positioned adjacent to the recliner. The resident stated he did not like asking for help, but he had a series of falls which injured his back. Resident #47 stated he still had back pain from the multiple falls. During an observation and interview on 8/14/24 at 8:36 a.m.,…

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 help obtain mental health services for a resident who was dealing with grief and the loss of his spouse for almost a year, for 1 (#41) of 26 sampled residents. Findings include: During an interview on [DATE] at 3:07 p.m., resident #41 said he was having problems dealing with some confusion and issues in his life. Resident #41 said his wife died in October of 2023 and he missed her. Resident #41 said his family visited, but he still missed his wife and expected to see her in her room at the cottage where they lived. He said someone may have talked to him at one time, but he was not sure. Review of resident #41's current care plan showed it was not updated, and no interventions were put in place for helping the resident deal with grief or loneliness. During an interview on [DATE] at 10:40 a.m., staff member G said she had visited with, and provided emotional support for, resident #41 following the death of his wife. Staff member G said 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 observation, interview, and record review, the facility failed to provide medications in a timely manner for 1 (#41) of 26 sampled residents, and the medications were provided late. Findings include: During an observation and interview on 8/13/24 at 10:10 a.m., staff member L had two syringes in her hand. Staff member L said she was on her way to give resident #41 his morning insulin. Staff member L said resident #41 was just going to his room, and she had not given the morning insulin yet. The medication was scheduled to be administered at 7:00 a.m., and this was three hours past the scheduled administration time. Review of resident #41's nursing progress note, dated 8/13/24 at 1:30 p.m., showed the insulin was given late this morning. The Elders BG was lower than usual, and the nurse waited for the resident to eat before giving insulin. It was after 10 a.m., before Elder got back to room, and insulin given. [sic] Review of resident #41's medication administration audit, dated 8/13/24, showed the insulin was administered at 10:11 a.m The blood sugar was 112 at 6:41 a.m.…

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 as needed psychotropic medications were limited to 14 days or had documented rationale for extended use by the physician, for 2 (#s 38 and 131) of 26 sampled residents. Findings include: 1. Review of resident #131's pharmacy progress notes, dated 5/10/24, showed a pharmacist identified the resident's daughter requested a sleep aid/antianxiety medication for resident #131. On 5/10/24, the pharmacist recommended increasing the Tylenol or consider melatonin for sleep or lorazepam PRN (as needed) for anxiety. Review of #131's physician orders, dated 5/21/24, showed clonazepam 0.25 mg was ordered once daily as needed (PRN) for insomnia or anxiety. The physician did not order a stop date for the PRN psychotropic medication. Review of resident #131's pharmacy progress note, dated 7/16/24, showed the pharmacist documented the clonazepam 0.25 mg once daily as needed for sleep was being continued. The pharmacist note showed the resident took the PRN clonazepam 14 out of 15 nights during August 2024. The pharmacist recommended…

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 obtain a signed consent for administration of a pneumococcal vaccine for 1 (#58) of 26 sampled residents. Findings include: Review of resident #58's pneumococcal immunizations consent form, dated 7/10/24, showed resident #58 was confused and unable to consent to administration of the pneumococcal vaccine. During an interview on 8/15/24 at 9:45 a.m., staff member B stated the nurse should have followed up with resident #58's legal representative and educated them on the risks and benefits of the pneumococcal vaccination. And allowed the legal representative to decline or consent to the vaccination. Review of the facility's policy, Influenza and Pneumococcal Immunization Policy, revised December 2022, showed: - Pneumococcal immunization status of all residents will be determined on admission regardless of date. - Vaccination will be offered to all patients who cannot provide documentation of previous vaccination status. Those who are unsure of or do not know their vaccination status will be immunized. - Pneumococcal Vaccine…

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 in interview and record review, the facility failed to ensure the process for entering and confirming medication orders was followed resulting in an incorrect dose being administered for 27 days for 1 (#1) of 3 sampled residents. The medication was an antiepileptic medication used for the control of behaviors. Findings include: During an interview on 4/22/24 at 1:39 p.m., NF1 stated resident #1 was admitted to the facility on [DATE], and was receiving hospice services due to his progressive dementia. NF1 stated resident #1 had been on Depakote for approximately 16 years. NF1 stated the medication was used to control behaviors. NF1 stated resident #1 had an increase in his behaviors which was initially attributed to the resident's diagnosis of Alzheimer's, and the overall decline in his condition. NF1 stated she found out about the dose change for the Depakote approximately one month after the change was initiated. Review of resident #1's MARs, dated December of 2023, January, and February of 2024, 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, interview, and record review, the facility failed to consistently monitor and maintain refrigerated food temperatures at safe levels, causing an elevated risk for foodborne illness in [Cottage Name]. This failure had the potential to affect all residents in [Cottage Name]. Findings include: During an observation of the kitchen in [Cottage Name] on 7/31/23 at 3:11 p.m., refrigerator temperature logs were located on the front door of all refrigerators and freezers, and dated July 2023. The refrigerator log document included the statement, Ideal temp between 36-40 degrees F. The document contained column headings for a.m. and p.m. Under both the a.m. and p.m. headings, subheadings were noted for time, temperature, initials, and action taken. During an interview on 8/2/23 at 1:35 p.m., staff member L reported she had been in her role as a cook for eight days. She stated staff member K had been checking the temperatures. When asked if she received any training on the refrigerator temperature monitoring, she stated, (Staff member K) was starting to show me how to do…

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 address a resident's preference for female caregivers, for personal cares, for 1 (#4) of 6 sampled residents. Findings include: Review of resident #4's nursing progress note, dated 6/16/23, showed resident #4 had family visiting, she was in the bathroom and needed assistance cleaning up. Family found a staff member to assist the resident, however, the only staff available was a male CNA, and she refused to have him help her in the bathroom. Review of resident #4's pharmacy note, dated 6/30/23, showed, Behaviors: . refusing cares from male CNAs. Review of resident #4's care plan, with an initiation date of 3/27/23, showed a lack of identification of the resident's preference for female caregivers with personal hygiene cares. During an interview on 8/3/23 at 8:20 a.m., NF4 stated when the CNA or nurse was a male, resident #4 just pulled up her pants without wiping since she did not want a male caregiver to help her in the bathroom. She stated resident #4 would then spend her day in those unclean clothes, unknown to staff.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive resident-centered care plan for a resident with dementia with behaviors, for 1 (#1), and failed to identify, document, and utilize behavioral interventions for a resident who exhibited behaviors, and who was prescribed an antipsychotic medication to treat the behaviors, for 1 (#24) of 6 sampled residents. Findings include: 1. During an observation and attempted interview on 7/31/23 at 2:24 p.m., resident #1 was sitting in her recliner in her room. Resident #1 was awake and loudly singing a counting song. The resident did not stop singing or interact when her name was spoken several times. Resident #1 did not respond to any of the questions asked by the surveyor. During an interview on 8/2/23 at 7:45 a.m., staff member D stated resident #1 was frequently vocal, but not mean to the staff or other residents. Staff member D stated resident #1 usually slept in late and got verbally louder as the day went…

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 perform a skin assessment on a resident's sacrum for two weeks for 1 (#34) of 2 sampled residents. This deficient practice resulted in the evolution of an existing pressure ulcer from intact skin with no open areas, to open exposed tissue. Findings include: Review of resident #34's hospital Discharge summary, dated [DATE], showed the resident had a sacral, deep tissue injury and scattered blanching red areas. No open areas or drainage. This area was covered with a border dressing during her stay in the hospital. Review of resident #34's treatment administration record, dated June 2023, failed to show a physician's order for wound care or observation of the sacrum wound, upon readmission to the facility. Review of resident #34's nursing progress notes, dated 6/23/23 - 7/6/23, failed to show assessments of the sacral area or observations of the border dressing. Review of resident #34's shower records, dated 6/22/23 - 7/6/23 showed the resident had…

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

Based on observation, interview, and record review, facility staff failed to ensure 1 (#142) of 1 sampled resident was provided with durable medical equipment necessary to prevent adverse sleep events at night. Findings include: During an observation and interview on 7/31/23 at 1:28 p.m., resident #142 was sitting in a recliner in her room. The resident was receiving oxygen via nasal cannula. Resident #142 said she had been in the facility for four or five days after spending about a week in the hospital. Resident #142 said she only used oxygen at home when she was up and active. When asked, the resident said she had a BiPAP machine at home, and she used it every night. Resident #142 said she had been using a BiPAP for at least eight years. Resident #142 said she slept much better when she was using her BiPAP. The resident did not have a BiPAP machine in her room. During an interview on 7/31/23 at 2:06 p.m., NF2 said resident #142 had a BiPAP at home, and the resident used it every night. NF2 said facility staff had not asked him about resident #142's BiPAP. NF2 said he had no…

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

Based on observation, interview, and record review, the facility failed to attempt, document, or care plan nonpharmacological interventions for a resident's disruptive behaviors and agitation, prior to the initiation of an antipsychotic medication, for 1 (#24) of 2 sampled residents. Findings include: Review of a Facility Reported Incident, submitted to the State Survey Agency, dated 2/20/23, showed resident #24 was involved in an altercation with another resident. The report showed resident #24 kicked another resident because the other resident was calling out repeatedly, and resident #24 wanted her to be quiet. The incident showed an increase in behaviors by resident #24, and resulted in the initiation of an antipsychotic medication. During observations on 7/31/23 between 2:30 p.m. and 4:00 p.m., and an interview with resident #24, she stated, she liked to people watch. Resident #24 wheeled herself around the cottage, looking out various windows and glass doors. The resident was not observed to be kicking furniture or wandering into other resident rooms. During an interview on…

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

Based on interview and record review, the facility failed to ensure a physician's order for antibiotics contained all necessary elements, specifically the duration of the antibiotic medication, for 1 (#59) of 3 sampled residents. The deficient practice resulted in the resident receiving five more doses than the provider ordered. Findings include: Review of resident #59's provider order, dated 5/23/23, showed an order for cephalexin (antibiotic) 500 mg two capsules three times a day for seven days. The order end date field, within the detail of the order in the EMR, showed indefinite. Review of resident #59's MARs, dated for May and June of 2023, showed doses of the antibiotic cephalexin were given three times a day from 5/24/23 through 5/30/23. The MARs, dated 5/31/23 and 6/1/23, showed two doses (8:00 a.m. and 5:00 p.m.) were given, and the 12:00 p.m. dose was documented as not available on either day. The MAR, dated 6/2/23, showed a single dose was given at 8:00 a.m. From 5/31/23 to 6/2/23, the five extra doses were given, but the medicaiton should have stopped on 5/30/23. During…

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.