The PEARL AT KRUSE WAY

In the surveyor’s words

From the most serious findings on record at The PEARL AT KRUSE WAY, in the surveyor’s own words.

• Actual harm, isolatedF686Nov 24, 2021

  Based on interview and record review it was determined the facility failed to provide necessary care and services to prevent pressure ulcers for 1 of 4 sampled residents (#8) reviewed for skin conditions. This caused Resident 8 to develop a facility acquired pressure ulcer and placed residents at risk of developing pressure ulcers. Findings include: Resident 8 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/13/21 Admission Nursing Database indicated Resident 8 did not have a pressure ulcer. […]

• No harm, potential for more than minimal, widespreadF725Jul 14, 2023

  Based on interview and record review the facility failed to provide sufficient nursing staff to ensure residents attained or maintained their highest practicable mental, physical and psychosocial well-being for 3 of 3 sampled residents (#s 2, 48 and 162) reviewed for staffing. This placed residents at risk for unmet ADL care needs. Findings include: A list provided by the facility on 7/14/23 indicated the facility had 4 residents who required a mechanical lift for transfers and two other residents who required two staff for transfers. Residents indicated the following concerns: - A concern reported on 6/26/23 indicated Resident 48 waited up to 45 minutes for for assistance, including waiting to get assisted to the toilet and off the toilet. It was indicated weekends were worse. […]

• No harm, potential for more than minimal, widespreadF865Jul 14, 2023

  Based on interview and record review it was determined the facility failed to develop a Quality Assessment and Assurance (QAA) program that identified quality deficiencies and developed and implemented action plans to correct identified quality deficiencies. The facility failed to conduct an analysis of quality data, design interventions, test those interventions, and determine if the desired outcome was achieved or sustained for 1 of 1 facility reviewed for QAPI. This failed practice placed all residents at risk for not receiving the care and services for optimal resident outcomes. […]

• No harm, potential for more than minimal, patternF655Aug 2, 2024

  Based on interview and record review it was determined the facility failed to provide a summary of the baseline care plan to 5 of 5 sampled residents (#s 19, 124, 125, 130, and 133) reviewed for pain, rehab services and unnecessary medication. This placed residents at risk for being uninformed of their plan of care. Findings include: 1. Resident 19 admitted in 7/2024 with diagnoses including aftercare following joint replacement surgery and depression. The Admission MDS dated [DATE] indicated Resident 19 was cognitively intact. No information was found in the resident's clinical record to indicate a baseline care plan or summary was provided to the resident. On 7/29/24 at 11:26 AM Resident 19 stated she/he did not receive any care plan paperwork. […]

• No harm, potential for more than minimal, patternF684Aug 2, 2024

  Based on interview and record review it was determined the facility failed to ensure physician orders were followed for 4 of 8 sampled residents (#s 125, 135, 181, and 228) reviewed for medications. This placed residents at risk for reduced medication efficacy and adverse medication side effects. Findings include: 1. Resident 228 admitted to the facility in 7/2024 with diagnoses including hypertension and prostate cancer. An 8/2/24 facility audit of Resident 228's medication administrations from 7/27/24 through 8/1/24 revealed the following: - On 7/31/24 seven medications were administered one hour and 38 minutes to two hours and 49 minutes late. - On 8/1/24 four medications were administered one hour and 30 minutes late. […]