Waters Of Chesterfield Skilled Nursing Facility

Based on interview and record review, the facility failed to provide residents and/or their representatives with written notice of transfer/discharge and bed hold policy for 3 of 3 residents reviewed for hospitalizations. (Residents 2, 30, and 46) Findings include: 1.Resident 2's clinical record was reviewed on 3/25/26 at 2:17 p.m. Diagnoses included unspecified heart failure, oropharyngeal dysphagia (difficulty swallowing), and gastro-esophageal reflux disease (GERD).A 2/24/26, quarterly Minimum Data Set (MDS) assessment indicated the resident was moderately cognitively impaired and utilized a feeding tube.A 11/7/25, discharge MDS assessment indicated the resident discharged with a return anticipated. A 11/7/25, nursing progress note indicated Resident 2's blood sugar was checked and read as high. The on-call physician was contacted and provided an order to send the resident to the emergency room for evaluation and treatment.A 11/7/25, online eInteract Change in Condition assessment indicated the resident had high blood sugar and the on-call physician provided an order to send 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 observation, record review, and interview, the facility failed to follow enhanced barrier precautions (EBP) during medication administration for 1 of 1 resident reviewed for tube feedings. (Resident 2)Findings include:Resident 2's clinical record was reviewed on 3/25/26 at 2:17 p.m. Diagnoses included unspecified heart failure, oropharyngeal dysphagia (difficulty swallowing), and gastro-esophageal reflux disease (GERD).Current orders include the following: EBP related to PEG (gastrostomy) tube for infection prevention (1/14/26).A 2/24/26, quarterly, Minimum Data Set (MDS) assessment indicated the resident was moderately cognitively impaired and utilized a feeding tube.A 2/12/26, EBP care plan indicated for staff to follow the EBP guidelines when providing care and coming into direct contact with potentially infected materials or devices. Direct care activities include device use such as feeding tubes. Interventions included reinforcing proper handwashing and following personal equipment protocols (2/12/26) and set up isolation per facility protocol, following EBP guidelines…

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 make prompt efforts to resolve a grievance for a resident requesting a vegetarian diet for 1 of 1 resident reviewed for concerns related to specialized diet (Resident B). Findings include: Resident B's clinical record was reviewed on 5/30/25 at 11:00 a.m. Current diagnoses included hypothyroidism, gastro-esophageal reflux disease, and hypertension. The resident was admitted to the facility in February 2025. The resident had a 2/25/25 physician's order for a general diet-regular textured- vegetarian diet (revised 3/12/25). An Admission/re-admission Assessment, opened on 2/24/25 and locked on 2/27/25, indicated the resident required a regular vegetarian diet. A 3/1/25, quarterly, Minimum Data Set (MDS) assessment indicated the resident was cognitively intact. A 5/22/25 quarterly dietary assessment, completed by the Registered Dietician, contained no dietary pretences nor mention of the resident's desire for a vegetarian diet. The clinical record lacked a formalized care plan to address a dietary preference for…

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

Based on observation, interview and record review, the facility failed to ensure food was prepared and served under safe and sanitary conditions. This deficient practice had the potential to impact 39 of 39 facility residents. Finding include: During a lunch meal service observation on 1/9/25 from 12:00 p.m. to 12:40 p.m. the following concerns regarding food handling, food distribution, hand washing, glove use, and prevention of cross contamination were made: The Acting Dietary Manager (ADM) was wearing gloves on both hands. He began meal services, touching meal tickets, meal trays, bowls, counter tops, lids, utensils, napkin wrapped silverware, and the food contact surface of plates with his gloved hands. He picked up cooked chicken nuggets/boneless chicken wings with his contaminated gloves and placed the chicken on meal plates. At 12:04 p.m., he left the kitchen through the rear door by the refrigerators and freezers. He touched the door handle with his gloved hands. He returned carrying dinner rolls in bags. With his soiled gloved hands, he touched the bag of the dinner rolls.…

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 develop and provide a menu to encourage intake and promote dignity for residents who received a pureed diet for 3 of 3 residents who received pureed diets. (Residents 1, 16, and 7) Findings include: A current Facility menu, item and portion size guide (spread sheets) for lunch on Thursday 1/9/25 indicated the following meals were menued to be served: Regular Diet: BBQ chicken wings, herb roasted potatoes, broccoli florets, chilled peaches, and a dinner roll. The Pureed Diet was menued to receive all of the above items in pureed form. During a lunch meal observation on 1/9/25 from 12:00 p.m. to 12:36 p.m., the following food items were served: Regular diet trays were served breaded chicken nuggets/boneless chicken wings with a side of BBQ sauce, steamed broccoli florets, roasted herbed potatoes, and pudding as a substitute for peaches. During an interview on 1/9/25 at 12:25 p.m., the Acting Dietary Manager (ADM) indicated pudding was 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 record review and interview, the facility failed to provide the appropriate 48-hour notification of Medicare A Non-coverage for 2 of 2 residents reviewed for Beneficiary Notifications. (Residents 37 & 38) Findings include: On 1/8/25 at 1:23 p.m., the SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review Forms were reviewed for Residents 37 and 38, and indicated the following: 1. Resident 37 was admitted to Medicare Part A Skilled Services on 7/24/24. The last covered day of Part A services was 9/10/24. The Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) and SNF Notice of Medicare Non-Coverage (NONMC) were reviewed with the resident's representative and signed on 9/10/24. A 9/9/24, Detailed Explanation of Non-coverage form indicated Resident 37 had reached the maximized functional potential for physical and speech therapy. 2. Resident 38 was admitted to Medicare Part A Skilled Services on 8/13/24. The last covered day of Part A services was 9/11/24. The SNF ABN and SNF NONMC were reviewed with the resident's 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 record review and interview, the facility failed to notify the physician as ordered for changes in daily weights for 1 of 1 resident reviewed for weight loss/gain. (Resident 5) Finding includes: Resident 5's record was reviewed on 1/9/25 at 2:24 p.m. Diagnoses included heart failure, hypertension, and unspecified edema. Physician's orders included, but were not limited to, a. Monitor 1600 millimeter (mL) fluid restriction daily, 360 mL per meal. The order was dated 11/21/24. b. Take daily weight and notify the physician for an increase of 3 pounds (lbs) in 24 hours or an increase of 5 lbs in 7 days. The order was dated 11/22/24. c. Give one torsemide (a diuretic) 40 milligrams (mg) tablet twice daily for edema. The order was dated 11/29/24. Review of the resident's documented weights, included, but were not limited to, the following: a. On 12/24/24, the resident's weight was 362.6 pounds. On 12/23/24, the resident's weight was 353.0 pounds. This was an increase of 9.6 pounds in 24 hours. The record lacked a physician notification regarding weight gain. b. On 12/27/24, 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 observation and interview, the facility failed to ensure insulin (a medication to treat diabetes mellitus) vials were dated when opened and disposed of when expired for 1 of 2 carts reviewed for medication storage. (200 hall cart) Finding includes: During a medication storage observation of the 200 hall cart, accompanied by RN 6 on [DATE] at 10:22 a.m., the following was observed: One open vial of Lantus (long-acting) insulin, dated [DATE]; the vial contained approximately 40 units. One open vial of Lantus (long-acting) insulin, undated; the vial contained approximately 260 units. One open vial of Novolog (rapid-acting) insulin, undated; the vial contained approximately 200 units. During an interview at the time of the observation, RN 6 indicated insulin was good for 28 days and the insulin dated [DATE] was expired and should no longer be used. The undated insulin pens had one or more doses used and should have been dated when opened. During an interview, on [DATE] at 11:37 a.m., the DON indicated…

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 care plans had measurable goals and individualized approaches for 4 of 14 residents reviewed for care plan development (Residents 44, 45, 4, and 19) Findings include: 1. Resident 44's clinical record was reviewed on 1/18/24 at 11:15 a.m. Current diagnoses included anxiety disorder, insomnia, hypertension, malaise, and acquired absence of right leg above the knee. An 11/2/23, quarterly, Minimum Data Set (MDS) assessment indicated the resident had no cognitive limitation, understood others and was understood by others, and displayed no maladaptive behaviors during the assessment period. The resident had a current, 11/2/23, care plan problem/need regarding insomnia. The goal to this problem was to achieve 6-8 hours of restful sleep. During an interview on 1/19/24 at 10:20 a.m., the Social Services Designee (SSD) indicated the facility did not have a method to measure restful sleep. 2. Resident 45's clinical record was reviewed on 1/17/24 at 11:25 a.m. Current diagnoses included lupus, bipolar disorder, schizophrenia,…

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 review and revise care plans for 1 of 14 resident reviewed for care plan revision (Resident 4). Findings include: Resident 4's clinical record was reviewed on 1/17/24 at 11:33 a.m. Current diagnosis included Alzheimer's disease, major depressive disorder, anxiety disorder, and unspecified psychosis. A 12/16/23, quarterly, Minimum Data Set (MDS) assessment indicated the resident had mild cognitive limitations, understood others and was understood by others, had moderate self-reported depression, received antipsychotic medication, antianxiety medication, and antidepressant medication daily, and displayed no maladaptive medications during the assessment period. The resident had a current, 5/31/22, care plan problem/need regarding cognitive impairment due to dementia. An additional approach to this visit was for the SSD to visit weekly and as needed. This approach originated 2/28/22. The resident had a current, 2/27/22, care plan problem/need depression, which contained a 6/23/22 note which indicated the resident stated 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 offer medically related social services to residents with a diagnosis of a major mental illness in relation to behavior monitoring, behavior management, updating care plans, and provision of personalized care for mental and behavioral health for 4 of 4 residents reviewed for provision of medically related social services (Residents 44, 45, 4 and 19) Findings include: 1. During a resident group interview on 1/17/24 at 10:30 a.m., Resident 44 indicated he suffered from insomnia and liked to sleep whenever he can. Staff woke him up for showers and such. When he said no he'd rather sleep, they say he refused care. During an interview on 1/22/23 at 11:08 a.m., Resident 44 indicated he had never told the facility he wanted to sleep at night. He had told the facility he wanted to sleep whenever he could sleep. Resident 44's clinical record was reviewed on 1/18/24 at 11:15 a.m. Current diagnosis included anxiety disorder, insomnia, hypertension, malaise, and acquired absence of right leg above the knee. A 10/28/23 ,…

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

Based on record review, interview, and observation, the facility failed to assess a resident at risk for nutritional decline and weight loss and failed to implement weight loss interventions for 1 of 3 resident reviewed for nutrition. (Resident 27) Findings include: The clinical record for Resident 27 was reviewed on 1/17/24 at 2:43 p.m. Diagnosis included nontraumatic subdural hemorrhage, essential hypertension, and Alzheimer's disease with early onset. Current physician's orders included pureed diet (may have oatmeal) (4/23/21) and house shake with meals for supplement- Give one container/serving by mouth, record percentage consumed (1/26/23). The resident's monthly weight record indicated the following: On 9/6/23 the resident weighed 131.6 pounds. On 10/1/23 the resident weighed 132.1 pounds. On 1/5/24 the resident weighed 117.0 pounds. (A loss of 15.1 pounds since the resident's last recorded weight 3 months prior.) The monthly weight record lacked a weight for November 2023 and December 2023. The resident's clinical record lacked a dietary progress note since he had resumed…

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 food was palatable for 5 of 5 residents interviewed in the Resident Council group interview. Findings included: During a meal service observation on 1/16/24 at 12:05 p.m., one hall tray cart had been prepared and sent to the halls for distribution. During an interview on 1/16/24 at 12:10 p.m., the dietary manager indicated he had forgotten to take food temperatures before serving the meals. During a meeting with the Resident Council group on 1/18/24 at 10:23 a.m., the following food - related concerns were expressed: 5 of 5 residents indicated hot food was served cold three times a week or more. The food being cold made it not enjoyable to eat. 4 of 5 residents indicated vegetables were overcooked and mushy three times a week or more. The fifth resident indicated they did not eat vegetables and therefore did not have an opinion. 5 of 5 residents indicated the food was bland, flat or without flavor three times a week or more. 5 of 5 residents indicated meat was hard, overcooked, or dry three times 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain therapy services in a timely manner for a resident who was admitted following a stroke for 1 of 3 resident reviewed for admission to facility. (Resident B) Findings include: The clinical record for Resident B was reviewed on 11/21/23 at 9:24 a.m. Diagnoses included history of stroke, hemiplegia (paralysis) affecting dominant right side, dysphagia following stroke, and metabolic encephalopathy. He was admitted to the facility on [DATE], following an acute hospital stay for the treatment of a stroke. An admission MDS (Minimum Data Set) assessment, dated 9/23/23, indicated the resident was severely cognitively impaired, was dependent for activities of daily living (ADLs), and had difficulty swallowing. A physician's order, dated 9/16/23, indicated PT (physical therapy), OT (occupational therapy), and ST (speech therapy) evaluation on admission, readmission, and/or as needed; may evaluate and treat if appropriate. A Physician Note, dated 9/19/23,…

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.