The Creston Health & Rehabilitation

Based on observation, interview and record review, it was determined the facility failed to assess and conduct weekly wound evaluations for pressure ulcer care for 1 of 3 sampled residents (#3) reviewed for pressure ulcers. This placed residents at an increased risk for delayed healing and inadequate treatment. Findings include: Resident 2 was admitted to the facility in 7/2024, with diagnoses including atherosclerosis of the arteries (build up of plaque in the arteries, narrowing them and reducing blood flow), diabetes, hypertension, chronic heart failure and atrial fibrillation. On 2/27/25 at 9:25 AM, 12:38 PM, and on 2/28/25 at 8:25 AM, Resident 2 was observed sitting in her/his electric wheelchair in her/his room or through the facility. Resident 2 was pleasant, alert and oriented with clear speech. On 2/28/25 at 10:32 AM, RN surveyor observed Resident 2's pressure ulcer located on her/his right buttock, ischial area (lower part of the pelvis) to be closed, smaller than the size of a penny, reddened area. Resident 2's 1/26/25 Weekly Skin Evaluation identified the resident had a…

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

Based on interview and record review it was determined the facility failed to ensure residents were fully informed and understood the binding arbitration agreement for 1 of 1 facility reviewed for binding arbitration agreements. This placed residents at risk of being uninformed regarding their legal rights. Findings include: On 10/14/24 at 1:01 PM Staff 1 (Administrator) stated the facility offered a Mediation and Arbitration Clause to residents upon admission. Staff 1 stated he and Staff 5 (Bookkeeper) were responsible for the process of explaining the agreement to residents upon admission. On 10/14/24 at 1:06 PM Staff 5 stated she was responsible to provide residents with information related the facility's Mediation and Arbitration Clause. Staff 5 stated the information was part of the admission handbook, she did not explain the arbitration process to residents nor did she obtain signatures with dates. On 10/14/24 at 1:06 PM Staff 1 acknowledged the facility did not have a clear process for providing information regarding binding arbitration agreements to residents.

Based on observation, interview, and record review it was determined the facility failed to ensure community use CBG monitors were cleaned with an approved disinfectant for 3 of 6 sampled units (2, 2D and 1B) observed during medication administration and random observations, failed to implement EBP (enhanced barrier precautions: gloves and gowns worn during high contact for wounds and indwelling devices) timely for 1 of 2 sampled residents (#5) reviewed for pressure ulcers, failed to transport linens in a sanitary manner, and failed to ensure a legionella water management plan for 1 of 1 facility. This placed residents at risk for cross contamination. Findings include: 1. On 10/8/24 at 8:34 AM Staff 15 (LPN) was observed to clean a community use CBG with an alcohol swab. Staff 15 was stopped prior to entering a resident's room to perform a CBG check. Staff 15 stated she used alcohol swabs to clean CBG machines and at times used bleach wipes. On 10/8/24 at 9:05 AM Staff 37 (LPN) sated she cleaned the community use CBG on the 1B hall with alcohol wipes. All residents with CBG orders…

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 it was determined the facility failed to ensure dignified language was used to address residents and their equipment for 1 of 1 facility and 1 of 2 sampled residents (#14) reviewed for dignity. This placed residents at risk for a decreased quality of life. Findings include: The Alzheimer's Association's Greater Missouri Chapter's 7/2017 Person Centered Care in Nursing Homes and Assisted Living revealed language is important in the change to person centered care. Language can either support change efforts or undermine them. Concepts of personalization and relationship-building cannot take root when a resident requiring assistance at mealtime is referred to as a feeder or when the act of walking is referred to as ambulation. Purposeful lives unfold in communities, not in facilities. The widely used language of long-term care continues to reflect an institutional orientation. Part of a change effort must be thoughtful consideration of the words and expressions used to describe the care provided and the way people and spaces are referred…

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 it was determined the facility failed to provide a homelike environment for 1 of 1 resident (#340) reviewed for hospice and in 1 of 1 facility reviewed for environment. This placed residents at risk for a lack of autonomy and living in an unkempt environment. Findings include: The facility's revised 7/3/23 Safe and Homelike Environment Policy directed staff in accordance with residents' rights, the facility would provide a safe, clean, comfortable and homelike environment. The facility would create and maintain, to the extent possible, a homelike environment that de-emphasizes the institutional character of the setting. 1. Resident 340 was admitted to the facility in 8/2024 with diagnoses including dementia. On 10/7/24 at 12:01 PM Resident 340 was observed in her/his room with no personalized items or decorations in the room. On 10/10/24 at 1:47 PM Resident 340 stated she/he would like something good to look at in her/his room. On 10/14/24 at 9:50 AM Staff 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 it was determined the facility failed to ensure a bed hold policy was provided to a resident when transferred to the hospital for 2 of 2 sampled residents (#s 16 and 33) reviewed for hospitalization. This placed residents at risk for lack of knowledge related to the right to return to the facility. Findings include: 1. Resident 16 was admitted to the facility in 2/2020 with a diagnosis of diabetes. Progress Notes revealed Resident 16 was discharged to the hospital on 6/24/24. Resident 16's clinical record did not indicate Resident 16 was provided a facility bed hold policy. An 8/11/24 quarterly MDS revealed Resident 16 was cognitively intact. On 10/7/24 at 10:25 AM Resident 16 stated she/he did not recall staff providing her/him a bed hold policy when she/he went to the hospital. On 10/10/24 at 12:51 PM Staff 2 (DNS) stated upon admission to the facility residents were provided a bed hold policy. Staff 2 stated usually the admission director provided a bed hold policy upon discharge, but currently there was no admission director. No additional…

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 it was determined the facility failed to ensure care plans were revised to accurately reflect the needs of residents for 4 of 13 sampled residents (#s 5, 7, 35, and 73) reviewed for accidents, pressure ulcers, position and mobility. This placed residents at risk for unmet needs. Findings include: 1. Resident 5 was admitted to the facility in 4/2024 with a diagnosis of paralysis. A 7/17/24 Pressure Injury investigation revealed a new DTI (Deep tissue injury: damage to the soft tissue beneath the skin caused by pressure or shear. Often appears as a dark purple or maroon area) to the inner knee. The cause of the injury was determined to be from her/his bedside table putting pressure on the knee. Resident 5's care plan was not updated to direct staff to monitor pressure on Resident 5's leg from the bedside table. On 10/11/24 at 9:11 AM Staff 2 (DNS) stated Resident 5 did not have sensation in her/his legs. When the wound nurse performed wound care to the resident's sacral region she found the inner knee DTI. The wound nurse identified…

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, it was determined the facility failed to provide an ongoing program to support individual activity interests and preferences for 4 of 4 sampled residents (#s 38, 51, 53 and 340) reviewed for activities. This placed residents at risk for isolation, lack of social interaction and engagement. Findings include: The facility's 2023 Activities Policy indicated the facility was to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan and preferences. Facility-sponsored group, individual and independent activities were designed to meet the interests of each resident, as well as support their physical, mental and psychosocial well-being. Special considerations would be made for developing meaningful activities for residents with dementia and/or special needs. 1. Resident 51 was admitted to the facility in 6/2024 with diagnoses including dementia. Resident 51's 7/1/24 Activity Care Plan revealed…

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 it was determined the facility failed to ensure a resident was provided restorative services and a resident with limited range of motion received appropriate treatment and services to prevent further decreases in range of motion for 4 of 10 sampled residents (#s 5, 7, 16 and 50) reviewed for ADLs and mobility. This placed residents at risk for decrease in range of motion and worsening contractures. Findings include: 1. Resident 5 was admitted to the facility in 4/2024 with a diagnosis of paralysis. A 6/5/24 Therapy RA Referral form revealed staff were to assist Resident 5 with exercises three times a week. Exercises included weights for upper body strength and edge of bed exercises. A 7/28/24 quarterly MDS revealed Resident 5 was cognitively intact. On 10/10/24 at 11:49 AM Resident 5 stated she/he was no longer getting therapy and was weaker. On 10/10/24 at 8:11 AM Staff 36 (RA) stated Resident 5 was just restarted on therapy on 10/8/24. Staff 36 stated initially Resident 5 was not able to sit at the edge of the bed because she/he…

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 it was it was determined the facility failed to ensure a medication error rate of less than 5%. The facility administration error rate was 19.23% with 5 errors in 26 opportunities. This placed residents at risk for an ineffective medication regimen. Findings include: Resident 343 was admitted to the facility in10/2024 with a diagnosis of heart disease. Epocrates Online (web based pharmacy resource) revealed levothyroxine (hormone replacement)should be taken 15 to 60 minutes before breakfast with a full glass of water at the same time daily. It also indicated the following drug to drug interactions: -levothyroxine and metformin (treats diabetes): deceases antidiabetic agent. -levothyroxine and metoprolol (treats high blood pressure) may decrease antihypertensive. -levothyroxine and sucubitril (treats heart failure and high blood pressure) may decrease antihypertensive. -levothyroxine and omeprazole (treats acid reflux) may decrease thyroid hormone levels. A current Order Summary Report revealed Resident 343 was to be administered…

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 it was determined the facility failed to ensure medications and biologicals were secured and accessible only to authorized personnel for 5 of 6 halls (1B, 1C, 1D, 2C and 2D) observed for secure medication and treatment carts. This placed residents at risk for misappropriation of medications and adverse medication consequences. Findings include: 1. On 10/8/24 the following occurred: -8:02 AM a treatment cart on 1D was observed to be unlocked, a CNA walked by the cart but did not lock the cart. -8:07 AM Staff 15 (LPN) locked the cart. Staff 15 stated she was not responsible for the the treatment cart which was unlocked and it was the night shift cart. Staff 15 stated the cart contained medicated creams and should be locked. 2. On 10/10/24 at 5:40 PM a medication cart located on the 1B hall was observed to be unlocked with no staff within sight of the cart. Staff 17 (Social Services Director) indicated the cart was to be locked and she informed a nurse who was in a resident's room. 3. On 10/8/24 at 3:53 PM a treatment cart was observed to be unlocked…

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 it was determined the facility failed to ensure foods were labeled and stored to ensure proper food storage practices were followed in 1 of 1 kitchen reviewed. This placed residents at risk for foodborne illness. Findings include: Review of the US FDA 2022 Food Code revealed: -food prepared and held cold must be clearly marked with date prepared or by day which the food shall be consumed or discarded. During the initial tour of the kitchen on 10/7/24 at 9:40 AM Staff 39 (Dietary Manager) verified and threw away the following undated and unlabeled items: Reach-in refrigerator: -A gyro sandwich wrapped in foil; -Prune juice poured into multiple glasses; -Three green salads. Walk-in refrigerator: -An opened container of chicken stock base; -Olives stored in a plastic container; -Cut tomatoes in a plastic container partially covered with plastic wrap; -Shredded carts stored in a plastic container. On 10/7/24 at 9:54 AM Staff 39 stated he expected all items in the refrigerators to be labeled, dated and covered, especially the opened…

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 it was determined the facility failed to obtain consents for the use of psychotropic medications for 2 of 6 sampled residents (#s 1 and 77) reviewed for medications. This placed residents at risk for the loss of the right to decline the use of psychotropic medications. Findings include: 1. Resident 1 was admitted to the facility in 5/2024 with a diagnosis of severe malnutrition. An 8/26/24 quarterly MDS revealed Resident 1 was cognitively intact. A 10/2024 MAR revealed Resident 1 was administered the following psychotropic medications: -Sertraline (antidepressant) with a start date of 5/24/24. -Trazodone (antidepressant also used to assist with sleep) with a start date of 5/24/24. Resident 1's clinical record did not include consents for the use of the psychotropic medications. On 10/10/24 at 12:38 PM Staff 2 (DNS) stated social services was to obtain consents for psychotropic medications. Staff 2 acknowledged consents were not completed for Resident 1's psychotropic medications. 2. Resident 77 was admitted to the facility in 3/2024 with…

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

Based on observation, interview, and record review it was determined the facility failed to honor a resident's preference for room layout for 1 of 2 sampled residents (#16) reviewed for choices. This placed residents at risk for depression. Findings include: 1. Resident 16 was admitted to the facility in 2/2020 with a diagnosis of diabetes. A 2/29/24 annual MDS revealed Resident 16 was cognitively intact, had weakness, and was in the facility for long term care. On 10/10/24 at 9:08 AM and 10/10/24 at 11:55 AM Resident 16 was observed in her/his room, a transfer pole was positioned on the left side of her/his bed, and Resident 16's spouse was observed in the bed to the right of the transfer pole. Resident 16 stated she/he was in a significant relationship with her/his spouse for 36 years. Resident 16 stated she/he wished the two beds were closer together to allow her/him to hold hands with her/his spouse. Resident 16 also stated she/he had PTSD (post traumatic stress disorder) and her/his spouse was able to calm her/him when she/he woke with vivid dreams. Resident 16 stated she/he…

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 it was determined the facility failed to ensure residents had an advance directive for 2 of 4 sampled residents (#s 1 and 16) reviewed for advance directives. This placed residents at risk for end-of-life choices not being honored. Findings include: 1. Resident 1 was admitted to the facility in 5/2024 with a diagnosis of severe malnutrition. An 8/26/24 quarterly MDS revealed Resident 1 was cognitively intact. An 8/29/24 Care Conference Meeting form revealed Resident 1 did not have an advance directive. The form did not indicate if staff provided Resident 1 information related to an advance directive or if the resident wanted to fill out an advance directive. On 10/10/24 at 11:38 AM Resident 1 stated she/he used to have an advance directive but did not know where it was and did not recall if the facility talked to her/him about an advance directive. Resident 1 also stated she/he definitely would not want tube feedings. On 10/10/24 at 9:11 AM Staff 9 (Social Services Coordinator) stated advance directive information was reviewed during care…

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

Based on interview and record review it was determined the facility failed to ensure a resident's emergency contact was notified of a resident's hospitalization for 1 of 2 sampled residents (#16) reviewed for hospitalization. This placed residents' representatives at risk for not being informed of a resident's change in medical condition. Finding include: Resident 16 was admitted to the facility in 2/2020 with a diagnosis of diabetes. Resident 13 was admitted to the facility 2/2020 with a diagnosis of dementia. An undated admission Record revealed Resident 13 was Resident 16's first emergency contact and Witness 1 (Acquaintance) was Resident 16's second emergency contact. An 8/4/24 quarterly MDS revealed Resident 13 was cognitively impaired. An 8/11/24 quarterly MDS revealed Resident 16 was cognitively intact. Progress Notes revealed on 6/24/24 Resident 16 vomited, was pale, clammy, and did her/his mental status was not at baseline. Resident 16 was transported to the local hospital for evaluation and treatment. There was no note to indicate Resident 16's first or second emergency…

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 it was determined the facility failed to ensure NOMNC (Notice of Medicare Non-Coverage) notifications were provided to 2 of 3 sampled residents (#s 75 and 290) and failed to provide SNF ABN (Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage) notifications to 2 of 3 sampled residents (#s 49 and 75) reviewed for Beneficiary Notification. This placed residents and their representatives at risk for lack of knowledge regarding their right to appeal and unknown financial liabilities. Findings include: 1. Resident 75 was admitted to the facility on [DATE] with Medicare Part A benefits. Resident 75's SNF Beneficiary Protection Notification Review provided by the facility indicated the resident's last covered day for Medicare Part A services was 5/27/24 and Resident 75 remained in the facility. According to the SNF Beneficiary Protection Notification form, the resident did not receive the required NOMNC notification to notify the resident or their representative…

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 it was determined the facility failed to ensure a system was in place to resolve resident grievances promptly for 1 of 1 resident (#57) reviewed for abuse. This placed residents at risk for unresolved grievances. Findings include: Resident 57 was admitted to the facility in 5/2022 with diagnoses including osteoarthritis (degenerative joint disease) and lower back pain. On 10/7/24 at 4:22 PM Resident 57 expressed she/he had concerns with her/his caregiver the other day. Resident 57 stated she/he told Staff 19 (RN) and Staff 38 (LPN) about her/his concerns and requested a grievance form be completed. On 10/9/24 at 8:23 AM Staff 1 (Interim Administrator) was unaware of Resident 57's concerns about the caregiver and at 9:51 AM Staff 1 confirmed a grievance form was not created for Resident 57's expressed concerns. On 10/9/24 at 11:03 AM Staff 19 confirmed Resident 57 spoke to her about her/his concerns regarding the caregiver on 10/7/24 and she told Staff 17 (Social Services Director) to complete a grievance form. On 10/14/24 at 5:43 AM Staff 38…

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 it was determined the facility failed to accurately assess residents for communication, dental, and transfers for 3 of 9 sampled residents (#s 1, 14 and 20) reviewed for communication, dental, and rehabilitation. This placed residents at risk for inaccurate assessments and unmet care needs. Findings include: 1. Centers for Medicare & Medicaid Services 10/2024 Resident Assessment Instrument (RAI) Version 3.0 Manual directed the following: -A resident who was able to express requests and ideas clearly should be assessed as understood. -A resident who experienced difficulty communicating some words or finishing thoughts but was able to be understood if prompted or given time, experienced delayed responses or required some prompting to make self understood should be assessed usually understood. -A resident who was able to clearly comprehend the speaker's message and demonstrated comprehension by words or actions/behaviors should be assessed as understands. -A resident who missed some part or intent of the speaker's message but…

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 it was determined the facility failed to provide appropriate treatment and services in the area of communication for 1 of 4 sampled residents (#53) reviewed for communication. This placed residents at risk for diminished quality of life and potential decline in their ability to carry out activities of daily living. Findings include: Resident 53 was admitted to the facility in 7/2021 with diagnoses including dementia. Resident 53's 9/22/24 Quarterly MDS revealed the resident was severely cognitively impaired and her/his ability to hear was highly impaired. Resident 53's 10/1/24 Communication Problem Care Plan revealed the following: -Use a dry erase board as needed to facilitate communication and understanding. -Use alternative communication tools as needed, such as a communication book/board, writing pad, gestures, signs and pictures. -9/15/21: The resident was not a candidate for hearing aids per family report. On 10/7/24 at 12:37 PM Resident 53 was observed in her/his room in bed. Resident 53 stated she/he was a little bit deaf 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, interview and record review it was determined the facility failed to provide the necessary care and services to maintain personal hygiene for 1 of 5 sampled residents (#51) reviewed for ADLs. This placed residents at risk for poor personal hygiene. Findings include: Resident 51 was admitted to the facility in 6/2024 with a dignoses including dementia. Resident 51's 9/15/24 Quarterly MDS indicated her/his cognition was moderately impaired and she/he required assistance or supervision with personal hygiene. Resident 51 was observed from 10/7/24 at 1:30 PM to 10/11/24 at 12:08 PM with a significant amount of chin hairs. On 10/9/24 at 8:37 AM Resident 51 stated she/he did not want chin hairs and needed help to shave them. The 10/11/24 [NAME] (bedside care plan) directed staff to shave Resident 51 as necessary. On 10/11/24 at 9:57 AM Staff 43 (CNA) stated she obtained information to care for Resident 51 from the [NAME]. On 10/11/24 at 11:30 AM Staff 28 (LPN) confirmed Resident 51 had long chin…

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 it was determined the facility failed to ensure residents were free from accident hazards for 3 of 6 sampled residents (#s 6, 50 and 60) reviewed for accidents. This placed residents at risk for falls and adverse medication consequences. Findings include: 1. Resident 6 was admitted to the facility 12/2022 with a diagnosis of diabetes. A care plan revised on 6/8/24 revealed Resident 6 was to be transferred by two staff. A 9/29/24 quarterly MDS revealed Resident 6 was cognitively intact. On 9/18/24 Witness 2 (Complainant) reported facility staff was observed to transfer Resident 6 with one staff and not two. It was reported Resident 16 was fearful during the transfer but did not fall. On 10/8/24 at 10:42 AM Witness 2 stated on 9/18/24 Witness 3 (Community Nurse) was entering Resident 6's room and a CNA who was already in the room was transferring Resident 6 with a mechanical device and no additional staff were in the room. On 10/8/24 at 8:11 PM Staff 31 (CNA) stated she recalled a day when she transferred Resident 6, the resident's legs became weak…

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 it was determined the facility failed to provide treatment and services to correct ongoing signs of depressive behavior for 1 of 1 sampled resident (#20) reviewed for behaviors. This placed residents at risk for not maintaining their highest practicable physical, mental and psychosocial well-being. Findings include: Resident 20 was admitted to the facility in 9/2022 with diagnoses including depression and adjustment disorder (a group of symptoms, such as stress, anxiety, feeling sad or hopeless, and physical symptoms that can occur after you go through a stressful life event). A review of Resident 20's Patient Health Questionnaire-9 (PHQ-9, a nine-item diagnostic tool used to assess for the presence and severity of depressive symptoms and a possible depressive disorder in adult patients in primary care settings) from 3/2024 through 9/2024 revealed the following: -On 3/10/24 the resident scored a 3, indicating she/he felt little interest or pleasure in doing things nearly every day. This score indicated minimal depression. -On 6/9/24…

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 it was determined the facility failed to obtain and provide routine medication for 2 of 5 sampled residents (#s 33 and 49) reviewed for unnecessary medications. This placed residents at risk for not receiving prescribed medications. Findings include: 1. Resident 33 was admitted to the facility in 12/2021 with diagnoses including chronic respiratory failure with hypoxia (a condition in which the body does not have enough oxygen in the blood). a. Resident 33's 9/17/24 Physician Order indicated the resident was prescribed Vitamin B12, one time a day due to a vitamin deficiency. Resident 33's 9/2024 MAR indicated Vitamin B12 was not available on 9/18/24, 9/19/24, 9/20/24, 9/21/24, 9/22/24 and 9/23/24 which resulted in the resident not receiving the medication. On 10/10/24 at 12:50 PM Staff 19 (RN) reviewed Resident 33's MAR and stated when medications were not available, the charge nurse should be notified. Staff 19 stated Resident 33 went too many days without her/his Vitamin B12 and that's a problem. Staff 19 stated she was unaware…

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 it was determined the facility failed to ensure a resident was monitored for side effects of antidepressants for 1 of 5 sampled residents (#1) reviewed for unnecessary medications. This placed residents at risk for an adverse medication regimen. Findings include: Resident 1 was admitted to the facility in 5/2024 with a diagnosis of severe malnutrition. Resident 1's 10/2024 MAR revealed Resident 1 was administered trazodone (antidepressant which can also help with sleep) daily with a start date of 5/24/24 and sertraline (antidepressant) daily with a start date of 5/24/24. A care plan initiated 5/31/24 revealed Resident 1 was administered antidepressants and potential side effects included drowsiness, suicidal thoughts, confusion, and increased falls. Review of Resident 1's clinical record did not indicate staff monitored her/him for psychotropic medication side effects. On 10/10/24 at 12:38 PM Staff 2 (DNS) stated staff were to document psychotropic medication side effect monitoring on the MARs. Staff 2 acknowledged staff did not monitor Resident…

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 it was determined the facility failed to ensure a follow-up dental exam was scheduled for 1 of 4 sampled residents (#16) reviewed for dental. This placed residents at risk for delayed treatment. Findings include: Resident 16 was admitted to the facility in 2/2020 with a diagnosis of diabetes. A 7/23/24 Progress Note indicated all of Resident 16's teeth were extracted. An 8/11/24 quarterly MDS revealed Resident 16 was cognitively intact. An 10/2024 Upcoming Appointment Requests list revealed Resident 16 was not on the list to be seen by a dentist. On 10/7/24 Resident 16 stated her/his teeth were pulled a few months prior, there were no follow-up appointments made and she/he wanted dentures. On 10/11/24 at 9:53 AM and 10/11/24 at 10:20 AM Staff 17 (Social Services Director) stated a dentist came to the facility two to three times a year. Staff 17 stated after teeth were pulled a resident's gums healing time varied from resident to resident and a resident needed to to be examined to determine if denture fitting was appropriate. Staff…

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

Based on interview and record review it was determined the facility failed to follow physician orders and provide correct oxygen administration for 1 of 3 sampled residents (#12) reviewed for physician orders. This placed residents at risk for improper oxygen administration. Findings include: Resident 12 admitted to the facility in 8/2020 with diagnoses including diabetes and kidney disease. 1. The 3/26/24 Hospital After Visit Summary revealed an order to increase Resident 12's oxygen via nasal cannula to 3/lpm (liters per minute). The March 2024 TARS revealed the following dates and shifts when oxygen was administered incorrectly: -3/26/24 night shift - 2/lpm -3/30/24 day, evening and night shift - 4/lpm -3/31/24 day and evening - 4/lpm On 7/23/24 at 12:15 PM Staff 15 (LPN Resident Care Manager) verified Resident 12's oxygen administration orders were not followed on 3/26/24, 3/30/24 and 3/31/24. 2. The RN Educator website instructed a (regular) oxygen face mask was used for oxygen flow rates from 6 - 12/lpm. A minimum of 6/lpm of oxygen flow was needed to prevent re-breathing 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 it was determined the facility failed to ensure licensed nursing staff possessed the competencies and skill sets necessary related to oxygen administration for 1 of 3 sampled residents (#12) reviewed for physician orders. This placed all residents at risk for unsafe oxygen administration. Findings include: The RN Educator website instructed a (regular) oxygen face mask was used for oxygen flow rates from 6 - 12/lpm (liters per minute). A minimum of 6/lpm of oxygen flow was needed to prevent the rebreathing of exhaled carbon dioxide. Resident 12 admitted to the facility in 8/2020 with diagnoses of diabetes and kidney disease. Resident 12's 3/26/24 Progress Note revealed she/he complained of difficulty breathing, her/his O2 sat was 88% - 92% (normal range is 95% - 100%), and the resident's oxygen was increased to 3/lpm via face mask. The 4/10/24 Progress Notes revealed the following: -2:44 PM: The previous shift placed Resident 12 on oxygen at 3/lpm via face mask. -2:44 PM: The oxygen flow rate was increased to 4/lpm via face mask. -3:37 PM:…

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 it was determined the facility failed to ensure wheelchairs were clean and sanitary for 1 of 3 sampled residents (#13) reviewed for equipment. This placed residents at risk for unclean wheelchairs. Findings include: Resident 13 admitted to the facility in 11/2019 with diagnoses including multiple sclerosis (disease which deteriorates the brain and spinal cord) and paraplegia (lower body paralysis). On 7/22/24 at 10:59 AM Resident 13's wheelchair was observed to have crumbs on the bottom cushion and small (approximately 1 inch by 1 inch) brown smudge marks to the bottom cushion and the inside of the left armrest. On 7/24/24 at 10:46 AM Resident 13's wheelchair was observed to have crumbs and a small brown smudge (approximately 1 inch by 1 inch) on the bottom cushion. On 7/26/24 at 12:30 PM Resident 13's wheelchair was observed to be dirty with crumbs on the bottom cushion. [The wheelchair did not appear to be cleaned as documented in the July 2024 TARS.] Resident 13's July 2024 TARS revealed her/his wheelchair was to be cleaned…

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 implement a Quality Assessment and Performance Improvement (QAPI) program which identified quality deficiencies, developed and implemented action plans to correct identified quality of care deficiencies. The facility failed to initiate a QA review related to staffing despite multiple concerns relayed to management by staff and residents and failed to respond to complaints and grievances filed by residents related to staffing shortages for 8/2023. This placed all residents at risk of not receiving the care and services for optimal resident outcomes. Findings include: The facility's QAPI policy and procedure, created in 2017 and reviewed 3/2022, stated the facility's QAPI plan would ensure a systematic, comprehensive, data-driven approach to care in order to prevent adverse events, reduce risk to residents and caregivers, promote safety and quality of care, and support each individual's choices and self identified quality of life. The QAPI plan is ongoing and comprehensive, dealing with the full range of services 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, interview and record review it was determined the facility failed to ensure residents were free from neglect. The facility failed to ensure residents received basic care for 4 of 4 sampled residents (#s 200, 300, 500, and 700) reviewed for ADL's. This neglect was due to the failure of the facility to provide adequate staffing which resulted in long call light times, lack of timely incontinence care and showers not completed on scheduled days. This failure placed all residents at risk for neglect of care. Findings include: According the the Centers for Medicare and Medicaid Services (CMS), Sec. 483.5, Neglect means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. 1. ADL AND INCONTINENCE CARE a. Resident 200 admitted to the facility on [DATE] with diagnoses including hip fracture and Parkinson's Disease. Resident 200's admission 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 interview and record review it was determined the facility failed to ensure residents were free from misappropriation of personal property for 2 of 2 sampled residents (#s 400 and 800) reviewed for misappropriation of property. This placed residents at risk for theft. Findlings include: 1. Resident 800 was admitted to the facility on [DATE] with diagnoses including amputation of the left leg below the knee and anxiety disorder. Resident 800's Quarterly MDS dated [DATE] revealed she/he was cognitively intact with a BIMS score of 15. On 8/28/23 the facility reported to the State Agency Resident 800 reported her/his credit/debit card had been stolen 7/2023. The resident initially thought the card was accidentally thrown away but subsequently learned charges were made to the card that she/he had not authorized. The facility initiated an investigation and made a referral to law enforcement. On 9/8/23 at 4:06 PM, Resident 800 confirmed the card was taken from her/his room in July 2023 when she/he left the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to provide ADL care to 4 of 4 sampled residents (#s 200, 300, 500 and 700) reviewed for ADLs. This placed residents at risk for unmet needs. Findings include: a. Resident 200 admitted to the facility on [DATE] with diagnoses including hip fracture and Parkinson's Disease. Resident 200's admission MDS dated [DATE] revealed no cognitive impairment with a BIMS score of 13. The MDS functional status section revealed the resident required extensive assistance with most ADLs, including assistance with showers. On 9/8/23 at 9:43 AM Witness 1 (Complainant) stated Resident 200 did not receive showers for several days after she/he was admitted due to the facility's staffing issues. Resident 200's bathing/shower logs were reviewed and no showers were documented from 7/21/23 through 8/3/23. On 9/18/23 at 3:30 PM, Staff 3 (RNCM) confirmed the facility had staffing issues and the bathing/shower logs reflected no showers were given to Resident 200. b.…

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 it was determined the facility failed to ensure sufficient staffing to meet resident care needs for 1 of 1 facility reviewed for sufficient and competent staffing. This placed residents at risk for delayed and unmet care needs. Findings include: 1 a. Resident 200 admitted to the facility on [DATE] with diagnoses including hip fracture and Parkinson's Disease. Resident 200's admission MDS dated [DATE] revealed no cognitive impairment with a BIMS score of 13. The MDS functional status section revealed the resident required extensive assistance with most ADLs, including assistance with showers. On 9/8/23 at 9:43 AM Witness 1 (Complainant) stated Resident 200 did not receive showers for several days after she/he was admitted due to the facility's staffing issues. Resident 200's bathing/shower logs were reviewed and no showers were documented from 7/21/23 through 8/3/23. On 9/18/23 at 3:30 PM, Staff 3 (RNCM) confirmed the facility had staffing issues and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to ensure Staff 9 (Agency CNA) met professional standards of care for 1 of 3 sampled residents (#500) reviewed for incidents. This placed residents at risk for unmet care needs. Findings include: OAR [PHONE NUMBER] Conduct Unbecoming a Nursing Assistant: A CNA, regardless of job location, responsibilities, of use of the title CNA, whose behavior fails to conform to the legal standard and accepted standards of the nursing assistant profession, or who may adversely affect the health, safety of welfare of the public, may be found guilty of conduct unbecoming a nursing assistant. Such conduct includes but is not limited to: (1) Conduct, regardless of setting, related to general fitness to perform nursing assistant authorized duties: (a) Demonstrated incidents of violent, abusive, neglectful or reckless behavior; (2) Conduct related to acheiving and maintaining clinical competency: (a) Failing to conform to the essential standards 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to follow physician's orders for 1 of 3 sampled residents (#200) reviewed for physician orders. This placed residents at risk for lack of medical care. Findings include: 1. Resident 200 admitted to the facility 7/2023 with diagnoses including hip fracture and Parkinson's Disease. Resident 200's admission MDS dated [DATE] revealed no cognitive impairment with a BIMS score of 13. On 9/8/23 at 9:43 AM Witness 1 (Complainant) stated a few weeks into her/his stay, Resident 200 told him she/he had neck and spinal pain and wanted x-rays. Witness 1 stated he contacted the facility and requested the x-rays be completed. However, the facility did not provide the x-rays and Resident 200 used an outside provider to get the x-rays completed. Resident 200 was not interviewed due to discharge. Clincial records reviewed indicated a secure conversation note written by Staff 3 (RNCM) on 8/7/23 at 3:58 PM to the facility's provider which requested an order…

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 it was determined the facility failed to maintain comfortable sound levels for 1 of 1 facility observed for environment. This placed residents at risk for an uncomfortable environment. Findings include: Resident 51 was admitted to the facility in 2020 with diagnoses including major depression and borderline personality disorder. On 6/13/22 at 10:05 AM Resident 328 (Former resident) reported in the two months prior to 6/13/22, Resident 51 yelled and screamed throughout the day and night. Resident 328 stated Resident 51's constant yelling caused her/him migraine headaches and disrupted family visits. Resident 328 stated she/he spoke to several staff members who acknowledged her/his concerns and informed her/him there was not much they could do. Multiple observations from 6/26/23 through 6/30/23 between the hours of 8:00 AM and 4:00 PM revealed Resident 51 intermittently yelled at different times of the day. Resident 51's voice was audible throughout the first floor, on the second floor and outside of the facility. On 6/27/23 at 2:08 PM Staff 24 (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 observation, interview and record review it was determined the facility failed to ensure residents were assessed for self-administration of medications and a physician order was in place for 1 of 6 sampled residents (#6) observed for medication administration. This placed residents at risk for adverse medication-related consequences. Findings include: Resident 6 was admitted to the facility in 11/2021 with diagnoses including chronic obstructive pulmonary disease (lung disease). Resident 6's 6/1/23 physician orders included the following: - fluticasone propionate suspension 50 mcg, two sprays in each nostril two times a day, to be administered by CMA/Licensed Nurse to ensure adherence. Resident 6's 6/2023 MAR indicated the following: - fluticasone propionate suspension 50 mcg, two sprays in each nostril two times a day, to be administered by CMA/Licensed Nurse to ensure adherence. Resident 6's health record revealed no physician order and no medication self-administration assessment which indicated the resident was able to safely store and self-administer medications. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to ensure a call light was readily accessible for 1 of 1 resident (#1) reviewed for accommodation of needs. This placed the resident at risk for delayed staff assistance. Findings include: Resident 1 was admitted to the facility in 2022 with diagnoses including dementia, history of traumatic brain injury, generalized weakness. According to the admission MDS assessment dated [DATE] and the most recent Quarterly MDS assessment dated [DATE] Resident 1 required extensive assistance for bed mobility. The resident's care plan updated on 5/20/23 under Falls section included the following intervention: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Observations on 6/27/23 at 9:46 AM revealed Resident 1 in bed with the head of bed near 40 degrees. Resident 1 was observed to have difficulty reaching items on her/his tray table. Resident 1 asked the surveyor for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to ensure MDS assessments were coded accurately for 3 of 7 sampled residents (#s 2, 18 and 35) reviewed for food and unnecessary medications. This placed residents at risk for inaccurate assessments. Findings include: 1. Resident 2 was admitted to the facility in 2021 with diagnoses including heart failure. Resident 2's 4/2/23 Quarterly MDS indicated no therapeutic diet or altered food texture. Resident 2's 6/2023 physician orders included the following: - Diabetic 2GM sodium diet, mechanical soft texture. On 6/29/23 at 10:52 AM Staff 22 (LPN Resident Care Coordinator) stated Resident 2 had a therapeutic diet with altered food texture and confirmed the 4/2/23 Quarterly MDS was not coded accurately. 2. Resident 35 was admitted to the facility in 2017 with diagnoses including anxiety disorder. Resident 35's 4/23/23 Significant Change MDS indicated the resident did not receive antipsychotic medication. Resident 35's 4/2023 physician orders…

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 it was determined the facility failed to implement the care plan related to positioning in bed for meals for 1 of 4 sampled residents (#1) reviewed for ADLs. This placed residents at risk for loss of independence, safety and comfort with eating. Findings include: Resident 1 was admitted to facility in 8/2022 with diagnoses of GERD (gastroesophageal reflux disease), dementia and weakness. The resident's Comprehensive Care Plan dated 8/14/2023 included a problem statement related to the resident's diagnosis of GERD. Interventions included to keep the head of Resident 1's bed upright during and for an hour after meals. Resident 1 was to have her/his food cut up into bite-size pieces and was to receive assistance with meals as needed. According to the admission MDS assessment dated [DATE] and the most recent Quarterly MDS dated [DATE] Resident 1 required extensive assistance of one staff person for bed mobility and set-up assistance for eating. On 6/26/23 at 10:39 AM…

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 it was determined the facility failed to provide ADL care to dependent residents for 2 of 4 sampled residents (#s 8 and 19) reviewed for ADL care. This placed residents at risk for unmet hygiene needs. Findings include: Resident 19 was admitted to the facility in 2020 with diagnoses including diabetes. Resident 19's 11/9/22 ADL Care Plan indicated Resident 19 required assistance of one staff for showering twice weekly and as necessary. Staff were to follow the facility's protocol for shower refusals and Resident 19 preferred showers during scheduled shower days. Resident 19's 5/21/23 Quarterly MDS indicated the resident was cognitively intact and bathing did not occur. Resident 19's 5/1/23 through 6/26/23 bathing task logs indicated the resident received a bed bath or shower on the following days: -6/2, 6/7, 6/12, 6/14, 6/21 and 6/26. A review of Resident 19's Progress Notes from 5/1/23 through 6/26/23 revealed no documentation Resident 20 was provided with additional bathing opportunities when bathing was not provided. On 6/26/23 at 10:56 AM…

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 it was determined the facility failed to provide support for a resident's choice of independent activities for 1 of 2 sampled residents (#34) reviewed for activities. This placed residents at risk for unmet psychosocial needs and isolation. Findings include: Resident 34 was admitted to the facility in 2023 with diagnoses including severe morbid obesity and [NAME]-Danlos syndrome (A disorder which affects connective tissue, primarily the skin, joints and blood vessel walls.) On 6/26/23 at 1:58 PM Resident 34 stated she/he was unable to get out of bed due to her/his medical conditions. The resident stated the only activity she had available was the TV and she/he was bored out of (her/his) mind. The resident stated the activities staff did not check on her/him to see if she/he needed or wanted anything else to do. No other independent activities such as books or puzzles were observed in the resident's room. Resident 34's 4/28/23 Activity Evaluation indicated 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 interview and record review it was determined the facility failed to consistently perform pressure ulcer assessments and wound care for 1 of 4 sampled residents (# 56) reviewed for pressure ulcer care. This placed residents at risk for worsening pressure ulcers. Findings include: Resident 56 was admitted to the facility in 2021 with diagnoses including paraplegia. A 9/14/21 Weekly Skin Evaluation determined Resident 56 acquired an unstageable left ischeal tuberosity (boney prominence at lower inner buttocks) pressure ulcer. The orders of care for this pressure ulcer continued until 6/2023 and included full skin assessments to be completed weekly. On 11/18/21 United Wound Healing began providing weekly sacral wound care and full skin assessments for Resident 56. Review of Resident 56's care records from 2/2023 through 4/2023 revealed United Wound Healing care was provided on 2/2/23 and then not again until 4/20/23. Review of Resident 56's Weekly Skin Evaluations from 2/2023 through 3/2023 performed by facility nursing staff indicated the assessments were performed only 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 observation, interview and record review it was determined the facility failed to follow physician orders for oxygen therapy for 1 of 1 sampled resident (#25) reviewed for oxygen. This placed residents at risk for unnecessary oxygen therapy. Findings include: Resident 25 was admitted to the facility in 2023 with diagnoses including sleep apnea. Resident 25's 6/2023 physician orders included oxygen therapy at two liters per minute as needed for shortness of breath. Resident 25's 6/2023 MAR revealed no oxygen administration was documented from 6/1/2023 through 6/28/23. On 6/26/23 at 10:24 AM and on 6/28/23 at 9:03 AM Resident 25 was observed with oxygen administration being provided via nasal cannula at two liters per minute. A review of Resident 25's 6/2023 Progress Notes revealed no evidence the resident complained of shortness of breath on 6/26/23 and 6/28/23. On 6/28/23 at 8:54 AM Staff 4 (CNA) stated Resident 25 was always on oxygen therapy when she/he was in bed. On 6/28/23 at 9:03 AM Staff 5 (RN) stated she had not assessed Resident 25 for shortness of breath 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 interview and record review it was determined the facility failed to ensure physician visits occurred as required for 1 of 5 sampled residents (#40) reviewed for unnecessary medications. This placed residents at risk for unassessed needs. Findings include: Resident 40 was admitted to the facility in 2021 with diagnoses including vascular disease. Review of Resident 40's health record revealed no documentation the resident was seen by her/his physician at least every 60 days. On 6/28/23 at 1:30 PM Staff 22 (LPN Resident Care Coordinator) stated Resident 40's physician did not see the resident very often. Staff 22 reviewed Resident 40's health record and was unable to locate physician notes or documentation to indicate the physician visited the resident as required. On 6/30/23 at 10:52 AM Staff 2 (DNS) was notified of the findings of this investigation and stated the physician was required to see the resident once every 60 days.

Based on observation, interview and record review it was determined the facility failed to ensure a medication pass error rate of less than 5%. There were three errors in 28 opportunities resulting in a 10.71% error rate. This placed residents at risk for reduced medication efficacy and adverse medication side effects. Findings include: Resident 6 was admitted to the facility in 11/2021 with diagnoses including chronic obstructive pulmonary disease (lung disease). Resident 6's 6/2023 physician orders included the following: - cholecalciferol tablet, 50 mcg, give two tablets one time a day; - fluticasone propionate suspension 50 mcg, two sprays in each nostril two times a day, to be administered by CMA/Licensed Nurse to ensure adherence; - polyethylene glycol 3350 powder, give 17 gm one time a day. On 6/28/23 from 7:31 to 8:00 AM Staff 21 (CMA) was observed for Resident 6's morning medication administration. During the observation, Staff 21 did not dispense and administer the cholecalciferol tablets, fluticasone propionate nasal spray or the polyethylene glycol 3350 powder. 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 observation, interview and record review it was determined the facility failed to ensure resident records were accurate for 2 of 10 sampled residents (#s 6 and 56) reviewed for medication administration and pressure ulcer care. This placed residents at risk for inaccurate health records and worsening pressure ulcers. Findings include: 1. Resident 6 was admitted to the facility in 2021 with diagnoses including chronic obstructive pulmonary disease (lung disease). Resident 6's 6/2023 physician orders included the following: - cholecalciferol tablet, 50 mcg, give two tablets one time a day; - fluticasone propionate suspension 50 mcg, two sprays in each nostril two times a day, to be administered by CMA/Licensed Nurse to ensure adherence; - polyethylene glycol 3350 powder, give 17 gm one time a day. On 6/28/23 from 7:31 to 8:00 AM Staff 21 (CMA) was observed for Resident 6's morning medication administration. During the observation, Staff 21 did not dispense and administer the cholecalciferol tablet, fluticasone propionate nasal spray or the polyethylene glycol 3350 powder.…

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.