Appleton City Manor

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care per standards of practice when staff failed to consistently assess and document complete, thorough, and accurate weekly skin assessments, failed to complete weekly wound tracking, and failed to obtain treatment orders for all wounds for one resident (Resident #1) with pressure ulcers (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) out of a sample of three residents. The facility census was 29. Review of the facility policy titled, Treatment/Services to Prevent/Heal Pressure Ulcers, undated, showed the following: -The facility will ensure a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing; -Pressure sores will be evaluated weekly and the nurse will document the size, location, odor (if any),…

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 ensure the home had registered nurse (RN) coverage including a RN assigned to serve as the Director of Nursing (DON) and able to complete needed DON duties on a full time basis when the facility's DON provided routine floor coverage prior to leaving employment at the facility. This resulted in leaving the facility being without a DON or RN. The facility census was 38. Review of the facility's policy titled, Nursing Services, undated, showed the following: -It is the policy of the facility to assure that there is sufficient qualified nursing staff available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being; -The facility will have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure residents safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as…

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 manage and account for all residents' personnel funds as required when staff failed to deposit residents' personal funds in excess of $50.00 into an interest bearing account and credit all interest earned back to residents for two residents (Resident #1 and #5) who received Medicaid services and when the facility failed to properly maintain an ongoing balance of and reasonable resident access to funds for seven residents (Resident #1, #5, #10, #21, #23, #28, and #100) personal funds. The facility census was 38. Review of the facility policy titled Resident Right - Protection/Management of Personal Funds, undated, showed the following: -It is the policy of the facility to protect and manage the personal funds of the resident in such a manner to acknowledge and respect resident rights; -If a resident chooses to deposit funds with the facility, upon written authorization of a resident, the facility will act as a fiduciary of the resident's funds and hold,…

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

Based on observation, interview, and record review, the facility failed to ensure residents were as free from accident hazards as possible when staff failed to follow physician orders to safely transfer one resident (Resident #7) using a Hoyer lift (mechanical device with a sling attached to lift and transfer a non-ambulatory resident). The facility had a census of 38. Review of the facility's policy, Hoyer Lift and Sit to Stand Lift Policy and Procedure, undated, showed the following: -Operating the Hoyer and Sit to Stand Lift is always and only a two-person operation. Do not operate lifts by self; -Any staff transferring a resident in a lift by themselves will be immediately terminated; -Always explain the steps to the resident; -Always double check sling attachment to Hoyer lift bar before lifting resident. Make sure colored loops match on both side and are completely on and secure to the hooks before transfer; -Lift a resident a few inches and double check all sling attachments again before continuing with transfer; -One aide operates the lift controls while the other aide…

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

Based on interview and record review, the facility failed to provide the services of a registered nurse (RN) for at least eight consecutive hours per day seven days per week. The facility census was 37. Review of the facility's policy Nursing Services, undated, showed the following: -It is the policy of the facility to assure that there is sufficient qualified nursing staff available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being; -Except when waived, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week; -The Director of Nursing (DON) may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents. 1. Review of the Monthly Work Schedule, dated July 2024, showed no RN scheduled on 07/07/24, 07/13/24, or 07/27/24. Review of the Monthly Work Schedule, dated August 2024, showed no RN scheduled on 08/04/24, 08/10/24, 08/11/24, 08/17/24, 08/24/24, and…

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

Based on observation, interview, and record review, the facility failed to ensure eight nurse aides (NA) (NA D, NA E, NA H, NA I, NA K, NA L, NA M, and NA N) of eight sampled NAs completed a certified nurse aide (CNA) training program within four months of employment at the facility as a nurse aide. The facility census was 38. Review of the facility policy, titled CNA Certification Policy, dated 8/22/22, showed the following: -This policy was made to ensure the residents' health and safety and to meet the residents' needs; -All nursing assistants shall successfully complete the entire basic course (including passing the final examination) of the nursing assistant training program and be certified within four months of employment; -Nursing assistants who have not successfully completed the nursing assistant training program prior to employment may begin duties as a nursing assistant and may provide direct resident care only if under the direct supervision of a licensed nurse prior to the completion of the seventy-five classroom hours of the training program; -Direct supervision means…

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 employ sufficiently qualified staff when the Director of Food and Nutrition Services (Dietary Manager) did not have required certification and/or experience. The facility census was 38. Review of the facility's policy titled, Dietary Services, undated, showed the following information: -The Director of Food Services (Dietary Manager) is designated by the facility administrator as responsible for the total dietetic service. The Dietary Manager receives frequently scheduled consultations from the qualified Dietitian; -Sufficient and competent dietary staff are employed to carry out the functions of the dietary services. Review showed the facility did not provide a policy regarding what the required qualifications were for a Dietary Manager. 1. Review of the facility's employee list showed the Dietary Manager was hired on 09/07/05. Review showed the facility did not provide documentation that the Dietary Manger met the minimum qualifications to serve in the Dietary Manger position. During an interview on 09/06/24, at 9:58…

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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety when the facility staff failed to keep food contact and non-food contact surfaces clean; when staff failed to ensure the refrigerators maintained proper temperatures for food storage; when staff failed to ensure stored food was properly stored/sealed; and when staff failed to ensure spoiled or contaminated foods were discarded. The facility census was 38. 1. Review of the Food and Drug Administration (FDA) Food Code (2022 edition) showed nonfood contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Review of the facility's policy, titled Dietary Services, undated, showed effective procedures were established for cleaning of all equipment and work areas. Review of the facility's policy, titled Infection Control- Food Services, undated, showed the facility was to store, prepare, distribute, and serve food under sanitary conditions following…

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 submit payroll based data to the Centers of Medicare and Medicaid Services (CMS) in a timely fashion as required. The facility census was 38. 1. Review of the facility's Payroll Based Journal (PBJ) Staffing Data Report, for fiscal year quarter two of 2024 (04/01/24 to 06/30/24), showed the facility triggered for failing to submit data for the quarter. During an interview on 09/06/24, at 9:21 A.M., the Administrator said that she had just started the PBJ for July, August, September. She found it had not been done for a while. She took the administrator position in July. She had completed the report for July, but was unable to go back and enter data for the previous period. She did not know who had been responsible for entering the report.

Based on interview and record review, the facility failed to implement and maintain an effective, comprehensive Quality Assurance and Performance Improvement (QAPI) plan that demonstrated identification, reporting, investigation, analysis, and prevention of adverse events, and documentation that demonstrated the development, implementation, and evaluation of corrective actions or performance improvement activities. The facility census was 38 at the time of survey. Review showed the facility did not provide a policy or procedure related to a comprehensive QAPI Plan. 1. Review of facility records showed the following: -The facility did not have documentation of Performance-Improvement-Plans (PIP's) or evidence of good-faith attempts to correct identified deficient practices;. -The facility did not have a current identified infection preventionist to participate. -The facility did not have documentation of medical director input as part of the QAPI process. During an interview on 09/09/24, at 12:51 P.M., the Administrator said she was unable to find any policy or procedure for QAPI.…

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 maintain documentation of maintaining a functioning Quality Assessment and Assurance (QAA) Committee that met at least quarterly with the required members. The facility census was 38. Review showed the facility did not provide a policy regarding a QAA Committee. 1. Review of facility records showed the following: -Staff did not have documentation to show a QAA Committee met a minimum quarterly with the required members. -The facility did not currently have an Infection Preventionist to participate in a QAA Committee. -The medical director did not attempt QAA Committee meeting regularly. During an interview on 09/09/24, at 12:51 PM, the Administrator said they did not have an infection preventionist and she could not determine when the medical director met with the rest of staff, or how often he visited as part of the QAA Committee.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to implement a complete and effective infection control program when staff failed to have a process in place to monitor for Legionella (severe form of pneumonia); failed to cover clean laundry when returning to resident rooms; failed to wear a mask or cover mouth when coughing; failed to use appropriate infection control measures to prevent or reduce the risk of spreading bacteria or other infectious causing contaminants when staff failed to provide a clean barrier for supplies for two residents (Resident #30 and #1); and when the home failed to implement an enhanced barrier precaution (EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities) policy. The facility census was 38. 1. Review of the facility policy, titled Legionella Policy, undated, showed the following: -The key to preventing Legionaries'…

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 implement an effective and complete antibiotic stewardship program when staff failed to track residents on antibiotics for various infections in the facility by not completing a current and ongoing antibiotic log of residents with active infections and failed to care plan antibiotic usage for two residents (Resident #30 and #15). The facility census was 38. Review of the facility's policy, Infection Control - Antibiotic Stewardship, undated, showed the following: -It is the policy of the facility to support the judicious use of antibiotics in accordance with State and Federal Regulations, and national guidelines; -The facility will establish protocols for antibiotic prescribing in accordance with national guidelines and treatment protocols; -The facility will establish algorithms for appropriate diagnostic testing (example: obtaining cultures) for specific infections; -The facility will summarize antibiotic use on a quarterly basis and use the data to…

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

Based on record review and interview, the facility failed to have a designated certified staff person as the infection preventionist (IP) who was responsible for the facility's infection prevention and control program (ICPC). The facility census was 38. Review showed the facility did not provide a policy related to the infection preventionist position. 1. During an interview on 09/04/24, at 11:30 A.M., the Administrator said she was unsure who was monitoring infections. She had taken the infection preventionist course, but had not taken the test. She thought possibly Licensed Practical Nurse (LPN) C was monitoring infections. During an interview on 09/04/24, at 3:35 P.M., LPN C said that he/she did not have infection preventionist certification and was not tracking infections. He/she said that the previous Director of Nursing (DON) and the previous Assistant Director of Nursing (ADON) had been monitoring the process. He/she did not know of any staff nurse in charge of infection prevention. During an interview on 09/06/24, at 11:50 A.M., LPN B said that he/she did not have an…

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 develop and implement abuse policies that established steps to prevent abuse, including proper screening of staff upon hire, when the facility failed to follow-up on requested Criminal Background Checks (CBC) for four staff (Nurse Aide (NA) D, Restorative Aide (RA) G, NA I, and Certified Medication Technician (CMT) F) out of ten sampled staff. The facility had a census of 38. Review of the facility's policy Policy and Procedures for New Hires, dated 09/09/13, showed the following: -All potential new hires have a background check initiated prior to beginning employment; -No new employee will be allowed to have direct contact with a resident until this steps has been completed. 1. Review of NA D's personnel record showed the following information: -Hire date of 05/09/22; -Staff requested a criminal background check on 05/09/22; -The facility did not document the completion/findings of the NA's criminal background check. 2. Review of RA G's personnel record showed the following information: -Hire date of 08/15/23; -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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a bed hold policy for one resident (Resident #36) who transferred/discharged to the hospital on two separate occasions. The facility census was 38. Review showed the facility did not provide a policy regarding bed holds. 1. Review of the Resident #36's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 04/24/24; -Resident had a responsible party; -Diagnoses included Alzheimer's disease and vascular dementia (disease affecting blood vessels in the brain causing changes to memory, thinking, and behavior). Review of the resident after visit summary from the hospital, dated 08/09/24, showed the resident was seen in the emergency room on [DATE] and discharged back to the facility on [DATE]. Review of the resident's medical record showed staff did not document providing written bed hold information to the resident, or responsible party, and did not have a copy bed hold provided to…

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

Based on record review and interview, the facility failed to complete and submit a quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff) within 92 days of the prior assessment for four residents (Residents #10, #3, #7, and #17). The facility census was 25. Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, Chapter 2, Assessments for the RAI, showed the following information: -The quarterly assessment is an Omnibus Budget Reconciliation Act of 1987 (OBRA) non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type; -The quarterly assessment is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored; -The assessment reference date (ARD) must be not more than 92 days after the ARD of the most recent OBRA assessment of any type. Review showed the facility did not provide a policy specific to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to have a process in place to ensure the timely and accurate identification of code status (whether a resident wished to receive cardiopulmonary resuscitation (CPR - an emergency treatment that's done when someone's breathing or heartbeat has stopped)) for all residents when staff failed to have physician orders related to code status for three residents (Resident #36, #30, and #3) and when the medical records of two residents (Resident #11 and #26) had conflicting code status information. A sample of 15 residents was selected for review out of a facility census of 38. Review showed the facility did not provide a policy regarding advance directives or code status processes. 1. Review of Resident #36's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of [DATE]; -Diagnoses included Alzheimer's disease and vascular dementia (disease affecting blood vessels in the brain causing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview the facility failed to provide pharmaceutical services to meet the needs of each resident when staff failed to obtain and administer medications as ordered after admission for one resident (Resident #4). The facility also failed to implement an effective system of destroying medications that could not be returned to the pharmacy a timely manner for sixteen residents (Resident #191, #11, #8, #19, #37, #18, #7, #22, #4, #15, #36, #190, #32, #29, #139, and #39) The facility census was 38. 1. Review of an facility policy, Medication Administration Policy and Procedure, undated, showed the following: -Medications are administered to residents in a safe, efficient, timely manner in accordance with accepted standards of practice and resident's usual preferred routine; -Medications are administered in accordance with the written orders of the attending physician/nurse practitioner; -If a dose of medication is withheld or refused, the dose will be circled on the front of…

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

Based on interview and record review, the facility failed to ensure pharmacy consultant recommendations were acted upon for gradual dose reductions (GDR - a stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) in an effort to reduce or discontinue psychoactive medications for one resident (Resident #1). The facility also failed to complete monthly drug regimen reviews for three residents (Resident #17, #11, and #26). The facility census was 38. Review of the undated facility policy titled Pharmacy Services - Drug regimen free From Unnecessary Drugs, undated, showed the following: -The intent of the policy was to ensure each resident's entire medication regimen was managed and monitored to promote or maintain the resident's highest practicable wellbeing; -The facility implements GDRs and non-pharmacological interventions prior to initiating or instead of continuing psychotropic medications; -Residents who use psychotropic drugs receive gradual dose reductions in an effort to…

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

Based on record review and interview, facility staff failed to complete an annual Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff) assessment for two residents (Resident #1 and #22) within the required 14 days from the assessment reference date (ARD). The facility had a census of 25. Record review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, Chapter 2, Assessments for the RAI, showed the following information: -The annual assessment is an OBRA (Omnibus Budget Reconciliation Act of 1987) comprehensive assessment for a resident that must be completed on an annual basis (at least every 366 days) unless an SCSA (Significant Change in Status Assessment) or an SCPA (Significant Correction to Previous Assessment) has been completed since staff completed the most recent comprehensive assessment; -The annual assessment ARD is the ARD of previous OBRA comprehensive assessment plus 366 calendar days, and ARD of previous OBRA Quarterly assessment plus 92 days. Review of 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 record review and interview, the facility failed to complete and electronically transmit a discharge and re-entry Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff) for three residents (Residents #3, #7, and #30). The facility census was 25. Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, Chapter 2, Assessments for the RAI, showed the following information: -The discharge assessment is an Omnibus Budget Reconciliation Act of 1987 (OBRA) non-comprehensive resident assessment; -The discharge assessment must be completed no later than 14 calendar days after the discharge; -The MDS must be transmitted no later than 14 calendar days after the MDS completion date. Review of a facility policy entitled Resident Assessment Instrument, revised September 2010, showed the following information: -A comprehensive assessment of a resident's needs shall be made within fourteen (14) days of the resident's…

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 develop a baseline care plan for all residents when staff failed to complete a baseline care plan with 48 hours of admission on e resident (Resident #39). The facility census was 38. Review of the facility's Resident Assessment Policy, undated, showed the following: -It is the policy of the facility to conduct and document comprehensive assessments on all residents admitted to the facility; -Comprehensive assessments describe the resident's capability to perform daily life functions and significant impairment in functional capacity; -Comprehensive assessments will commence upon admission or readmission of a resident and be completed no later than 14 days after admission or readmission. 1. Review of Resident #39's face sheet showed the following: -admitted on [DATE]; -Diagnoses included congestive heart failure (CHF - condition in which the heart can't pump enough blood to the body's other organs), chronic kidney disease stage 4 (CKD - kidneys are…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review, the facility failed to provide care per standards of practice when the staff failed to document full regular full assessments wounds, failed to update care plans of wounds, failed to notify the physician in a timely manner of new or changing wounds, and failed to ensure physician's orders were followed for all wounds for two residents (Resident #30 and #36). The facility census was 38. Review of the facility policy titled Treatment/Services to Prevent/Heal Pressure Ulcers, undated, showed the following: -The facility will ensure a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing; -Pressure sores will be evaluated weekly, and the nurse will document the size, location, odor (if any), drainage (if any), and current treatment order; -Nurse will notify physician anytime the pressure sore is showing signs 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, observation, and record review, the facility failed to ensure all residents received care to help maintain or improve range of motion (ROM - full movement potential of a join) when staff failed to ensure an ordered hand split was used to consistently, was monitored, and was care planned for one resident (Resident #23). The facility census was 38. Review showed the facility did not provide a policy related to restorative care or assistive devices. 1. Review of Resident #23's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 02/09/22; -Diagnoses included intracerebral hemorrhage (bleeding into the brain tissue), hemiplegia of left side, seizures, and muscle weakness. Review of the resident's restorative notes and assessments, dated 11/26/22, showed the resident admitted to facility with no contracture and did not use a positioning or support device. Review of the resident's care plan, revised on 06/13/24, showed the following: -Resident had impaired function and required staff assistance 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide incontinence care per nursing standards and in a manner to help prevent possible infection when staff failed to provide complete peri-care and failed to perform proper hand hygiene while providing peri-care for two residents (Resident #12 and #6). The facility census was 38. Review of the manual titled Nurse Assistant in Long Term Care Facility, 2001 Revision Edition, showed staff, when providing incontinent care, should wash the resident from front to back to prevent from spreading fecal matter from the anal area to the urethra (opening to bladder). Review of the facility's policy titled Incontinence Care, undated, showed the following procedure: -Wash all soiled skin areas and dry very well, especially between skin folds; -Change linen and apply linen with no wrinkles. 1. Review of Resident #12's face sheet (brief look at resident information) showed the following information: -admission date of 10/01/18; -Diagnoses included…

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 to ensure all residents received recommended interventions to help maintain acceptable parameters of nutritional status when staff failed to care plan, notify the physician of, and implement the Registered Dietitian (RD's) recommendations for a dietary supplement for one resident (Resident #33) who had been identified as experiencing some weight loss. The facility census was 38. Review of the facility's policy, titled Dietary Services, undated, showed the following information: -Dietary services meet the individual nutritional needs of each resident; -The dietician develops therapeutic diets to meet the specialized need of each resident; -All therapeutic diets are prescribed by the resident's physician and/or his/her designee. Review showed the facility did not provide a policy regarding documenting, obtaining, and implementing physician orders. 1. Review of Resident #33's face sheet (brief look at resident information) showed the following information: -admission date of 12/05/23; -Diagnoses included coronary artery…

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

Based on observation, interview, and record review, the facility failed to provide respiratory care per standards of practice for all residents when staff failed to obtain physician orders for use and care of a Continuous Positive Airway Pressure (CPAP- is a machine that uses mild air pressure to keep breathing airways open while asleep) machine and failed to care plane the use of the CPAP machine for one resident (Resident #15). The facility census was 38. Review of the facility's policy, titled Oxygen Administration, undated, showed staff to check physician's order for liter flow and method of administration. Review of the facility's policy, titled admission Orders, undated, showed the following information: -The facility will have physician orders for the resident's immediate care at the time of a resident's admission; -The admitting nurse will call the attending physician and clarify all orders on admission; -The admitting orders with be transcribed to the admission Physician Order Sheets (POS) once the orders are clarified or entered into the facility electronic medical record;…

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 one resident (Resident #36) was free from unnecessary psychotropic as needed (PRN) medications (medication affecting mind, emotions, and behavior) limited to fourteen days unless evaluated by the physician. The facility also failed to attempt a gradual dose reduction (GDR) for psychotropic medications for one resident (Resident #17). The facility census was 38. 1. Review of an undated facility policy Pharmacy Services - Drug Regimen Free From Unnecessary Drugs should the following: -PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited; -PRN orders for psychotropic drugs is limited to 14 days. Review of Resident #36's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 04/24/24; -Diagnoses included Alzheimer's disease and vascular dementia (disease affecting blood vessels in the brain causing changes to memory, thinking, and behavior). Review of the resident's significant change in status…

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 maintain all residents' records in a manner that was complete and accurate when the facility failed to document related to changes in conditions for two residents (Resident #39 and #36) that resulted transfers to the hospital. The facility census was 38. Review of facility records showed the facility did not provide a policy related to accuracy of or documentation in resident records, including changes in condition. 1. Review of Resident #39's face sheet showed the following: -admission date of 06/03/24; -Diagnoses included congestive heart failure (CHF - condition in which the heart can't pump enough blood to the body's other organs), chronic kidney disease stage 4 (CKD - kidneys are damaged and can't filter blood the way they should), chronic respiratory failure (condition that results in the inability to effectively exchange carbon dioxide and oxygen, and induces chronically low oxygen levels or chronically high carbon dioxide levels), type 2…

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

1. Please refer to event ID NJ1P12. Based on interviews and record review, the facility failed to ensure all residents were treated with dignity and respect when staff yelled and cursed in the presence of residents. A sample of seven residents was reviewed in a facility with a census of 37. 1. Review of Resident #1's face sheet (admission data) showed the following: -admission date of 07/01/19; -Diagnoses included Alzheimer's disease (confusion or cognitive impairment), dementia with other behavioral disturbances (confusion or cognitive impairment with behaviors); and major depressive disorder (feeling low or sad persistently). Review of the resident's significant change Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 02/21/24, showed the following: -Severally impaired cognition; -Disorganized thinking present. Review of the resident's care plan, revised on 02/16/24, showed the following: -Resident is dependent upon staff for getting emotional, intellectual, physical, social needs related to cognitive decline. Staff will converse 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.

1. Please refer to event ID NJ1P12. Based on interview and record review, the facility failed to ensure all residents' drug regimes were free from unnecessary drugs when staff failed to adequately monitor blood pressure as ordered for one resident (Resident #2), who received medications to help control blood pressure. A sample of four residents were reviewed, with a facility census of 37. Review showed the facility did not have a a policy regarding following physician's orders and monitoring with administration of medications. 1. Review of Resident #2's face sheet (admission data) showed the following: -admission date of 01/14/24; -No diagnosis listed. Review of the resident's care plan, dated 01/19/24, showed staff did not care plan regarding the resident's blood pressure medications. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 01/25/24, showed the following: -Memory problems; -Moderately impaired decision making; -Diagnoses included atrial fibrillation (irregular and often rapid heart rhythm,…

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.

1. Please refer to event ID NJ1P12. Based on interview and record review, the facility failed to ensure all residents' drug regimes were free from unnecessary drugs when staff failed to specify a diagnosis for use of a psychotropic medication for one resident (Resident #1). A sample of four residents was reviewed in a facility with a census of 37. Review showed the facility did not provide a policy regarding psychotropic medications. 1. Review of Resident #1's face sheet (admission data) showed the following: -admission date of 07/01/19; -Diagnoses included Alzheimer's disease (confusion or cognitive impairment), unspecified dementia with the other behavioral disturbances (confusion or cognitive impairment with behaviors). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 02/21/24, showed the following: -Severally impaired cognition; -Disorganized thinking is present; -Diagnosis include dementia and depression; -The resident was taking antianxiety medications. Review of the resident's care plan,…

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

Based on interviews and record review, the facility failed to ensure all residents were treated with dignity and respect when staff yelled and cursed in the presence of residents. A sample of seven residents was reviewed in a facility with a census of 37. 1. Review of Resident #1's face sheet (admission data) showed the following: -admission date of 07/01/19; -Diagnoses included Alzheimer's disease (confusion or cognitive impairment), dementia with other behavioral disturbances (confusion or cognitive impairment with behaviors); and major depressive disorder (feeling low or sad persistently). Review of the resident's significant change Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 02/21/24, showed the following: -Severally impaired cognition; -Disorganized thinking present. Review of the resident's care plan, revised on 02/16/24, showed the following: -Resident is dependent upon staff for getting emotional, intellectual, physical, social needs related to cognitive decline. Staff will converse with the resident while providing 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure all allegations of possible abuse were reported immediately to management and within two hours to the State Survey Agency (Department of Health and Senior Services - DHSS) when allegations were reported that one staff (Certified Nurse Aid (CNA A))cursed at two residents (Resident #1 and Resident # 2). The facility census was 45. Review of the facility's policy titled, Abuse, Prohibition, Prevention, Investigation, and Response, undated, showed the following: -It is the policy of the facility to take all reasonable and responsible measures to prevent the occurrence of abuse-including mental abuse-neglect, injuries of unknown sources, and misappropriation of resident property to ensure that all alleged, reported and suspected violations of Federal or State laws which involve mistreatment, abuse, neglect, avoidable accidents, incidents, injuries of unknown origin and misappropriation of resident property are reported to the state agencies within…

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 all residents' drug regimes were free from unnecessary drugs when staff failed to adequately monitor blood pressure as ordered for one resident (Resident #2), who received medications to help control blood pressure. A sample of four residents were reviewed, with a facility census of 37. Review showed the facility did not have a a policy regarding following physician's orders and monitoring with administration of medications. 1. Review of Resident #2's face sheet (admission data) showed the following: -admission date of 01/14/24; -No diagnosis listed. Review of the resident's care plan, dated 01/19/24, showed staff did not care plan regarding the resident's blood pressure medications. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 01/25/24, showed the following: -Memory problems; -Moderately impaired decision making; -Diagnoses included atrial fibrillation (irregular and often rapid heart rhythm, heart failure (heart muscle can't…

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 all residents' drug regimes were free from unnecessary drugs when staff failed to specify a diagnosis for use of a psychotropic medication for one resident (Resident #1). A sample of four residents was reviewed in a facility with a census of 37. Review showed the facility did not provide a policy regarding psychotropic medications. 1. Review of Resident #1's face sheet (admission data) showed the following: -admission date of 07/01/19; -Diagnoses included Alzheimer's disease (confusion or cognitive impairment), unspecified dementia with the other behavioral disturbances (confusion or cognitive impairment with behaviors). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 02/21/24, showed the following: -Severally impaired cognition; -Disorganized thinking is present; -Diagnosis include dementia and depression; -The resident was taking antianxiety medications. Review of the resident's care plan, revised on 03/18/24, showed the following:…

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 staff a registered nurse (RN) for at least eight hours a day, seven days a week. The facility census was 40. 1. Review of the October 2023 daily staffing postings showed the following: -On 10/11/23, there were no RN hours; -On 10/14/23, there were no RN hours; -On 10/15/23, there were no RN hours; -On 10/16/23, there were no RN hours. -The facility did not provide any other daily staffing posting for October 2023. Review of the facility's daily staffing sheet showed there was no RN scheduled for any shift on 10/11/23, 10/14/23, 10/15/23, 10/17/23, 10/18/23, 10/19/23, 10/20/23, 10/21/23, 10/22/23, 10/23/23, and 10/24/23. During an interview on 11/01/23, at 12:17 P.M., Licensed Practical Nurse (LPN) C said the following: -The Director of Nursing (DON) is the only RN employed at the facility; -There are no other RN's to work if he/she needs to be off; -This has been going on for at least three to four months. During an interview on 11/01/23, at 1:35 P.M., Nurse Assistant (NA) A said the following: -He/she thinks…

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 seven nursing aides (Nurse Aide (NA) A, NA E, NA F, NA G, NA H, NA I, and NA J) completed a a state approved certified nursing assistant (CNA) training program and competency evaluation program within four months of hire. The facility's census was 40. Review showed the facility did not provide a policy related to certification requirements time frames for CNAs. 1. Review of the personnel records showed the following: -NA A was hired as an NA on 05/09/22; -NA E was hired as an NA on 10/08/20; -NA F was hired as an NA on 05/02/19; -NA G was hired as an NA on 04/18/19; -NA H was hired as an NA on 04/20/23; -NA I was hired as an NA on 07/28/22; -NA J was hired as an NA on 02/27/23; -Staff did not have documentation of the NAs completing a state approved CNA training program or a competency evaluation within four months of hire. During an interview on 11/01/23, at 12:17 P.M., Licensed Practical Nurse (LPN) C said the following: -There are NA's that have been working at the facility more than four months; -The CNA classes…

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

Based on interview and record review, the facility failed to provide the annual individual performance review or evaluation and failed to provide regular in-service education based on these reviews for five nursing aides (Nurse Aide (NA) A, NA E, NA F, NA G, and NA I) . The facility census was 40. Review showed the facility did not provide a policy regarding annual individual performance reviews or education for aides. Review of the facility's current wide assessment showed the following: -The regulation outlines that individualized approach of the facility assessment is the foundation to determine staffing levels and competencies. The assessment must include a competency-based approach to determine the knowledge and skilles required among staff to ensure residents are able to maintain and attain their heighest practible physical, functional mental and psychosocial well-being and meet current professional strandards of pratice; -Staff competencies and annual training requirements per regulatory authority and/or facility policy 1. Review of personnel records showed the following: -NA…

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 have a registered nurse (RN) work eight consecutive hours seven days per week. The facility census was 31. Record review of the facility's Registered Nurse Coverage Policy, undated, showed the following information: -It is the policy of the facility to have RN coverage eight hours during the day for seven days a week; -The RN on duty will be responsible for supervision of the staff on duty and their provision of resident care; -The RN on duty will follow the job description of the RN. 1. Record review of the facility's provided nurse schedules, dated 07/01/2022 through 07/31/2022, showed no RN coverage on any shift for the following dates: -07/03/2022; -07/09/2022; -07/10/2022; -07/16/2022; -07/17/2022, -07/23/2022; -07/24/2022; -07/30/2022; -07/31/2022. Record review of the facility provided nurse schedules, dated 08/01/2022 through 08/15/2022, showed no RN coverage on any shift for the following dates: -08/06/2022; -08/07/2022; -08/13/2022; -08/14/2022. During an interview on 08/19/2022, at 7:46 A.M., Nurse Aide (NA) I…

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, observation, and interview, the facility failed to prepare food in accordance with professional standards of practice and protect food from possible contamination when staff did not maintain clean surfaces, touched food with bare hands, and staff did not wear proper hair coverings. The facility census was 31. 1. Record review of the 2013 Missouri Food Code showed the following information: -Equipment food-contact surfaces and utensils shall be clean to sight and touch; -The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; -Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris; -Nonfood-contact surfaces of equipment that are exposed to splash, spillage, or other food soiling or that require frequent cleaning shall be constructed of a corrosion-resistant, nonabsorbent, and smooth material; -Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues;…

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 maintain an infection control program that provided a safe and sanitary environment for all residents related to the Coronavirus Disease 2019 (COVID-19, an infectious disease caused by severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2)) when staff failed to wear face coverings properly while working with residents. The facility also failed to provide an effective, thorough program for the prevention of the growth of the Legionella bacteria (a bacteria which causes a respiratory disease when breathing in small droplets of water in the air that contain Legionella. It can become a health concern when it grows and spreads in human-made water systems.) in the facility water supply or where moist conditions existed. The facility census was 31. 1. Record review of the facility's policy, titled Infection Control Policy, revised 7/10/2022, showed the following: -The policy is based on information and advice from the Centers for Disease Control and Prevention (CDC). (The policy provided by the facility did…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to maintain a clean, comfortable, homelike environment when multiple light fixture covers were dirty, broken, missing the cover, or had dead bugs present in the fixture. The facility census was 31. Record review showed the facility did not provide a policy regarding cleaning or maintenance of the building. 1. Observation on 08/18/2022, at 11:20 A.M., showed the following: -Fluorescent light fixture in the hall, near room [ROOM NUMBER], had dead bugs in the cover; -Fluorescent light fixture in the hall, near room [ROOM NUMBER], had a broken cracked cover across the length of the fixture; -Fluorescent light fixture, across from the soiled utility room, had approximately 12 dead bugs in the cover; -Fluorescent light fixture in the hall, near resident room [ROOM NUMBER] and the bath/shower room on 100 hall, had approximately 14 dead bugs in the cover; -Fluorescent light fixture, at the end of 100 hall closest to the exit door, had numerous dead…

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 staff completed Nurse Aide (NA) Registry (registry which shows if someone has a Federal Indicator (indicates individuals who had a previous incident involving abuse, neglect, or misappropriation of property that would prevent the employee from working in a certified long-term care facility)) checks for three employees (Dietary Aide (DA) N, Licensed Practical Nurse (LPN) M, and Nurse Aide (NA) L). The facility census was 31. Record review showed the facility did not provide a policy regarding checking the NA registry upon hire. 1. Record review of Dietary Aide (DA) N's personnel record showed the following: -Hire/Start date of 4/12/22; -The facility had not completed the NA registry check for the DA. 2. Record review of Licensed Practical Nurse (LPN) M's personnel record showed the following: -Hire/start date of 6/09/22; -The facility had not completed the NA registry check for the LPN. 3. Record review of Nurse Aide (NA) L's personnel record showed the following: -Hire/start date 7/28/22; -The facility had not…

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 two nurse aides (Nurse Aide (NA) I and NA J) completed a certified nurse aide (CNA) training program within four months of employment in the facility as a nurse aide. The facility census was 31. Record review of the facility policy titled CNA Certification Policy, last reviewed and revised 08/22/2022, showed the following: -This policy is to ensure the residents' health and safety and to meet the residents' needs; -All nursing assistants shall successfully complete the entire basic course (including passing the final examination) of the nursing assistant training program and be certified within four months of employment; -Nursing assistants who have not successfully completed the nursing assistant training program prior to employment may begin duties as a nursing assistant and may provide direct resident care only if under the direct supervision of a licensed nurse prior to the completion of the seventy-five (75) classroom hours of the training program. Direct supervision means close contact, where 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 record review, observation, and interview, the facility failed to adequately equipped with a full call light system when call light pull cords were missing or when staff stored emergency call light pull cords where residents could not access the pull cord for staff assistance. The facility census was 31. Record review showed the facility did not provide a policy addressing the call light system. 1. Observation on 08/18/2022, at 11:30 A.M., showed the following: -room [ROOM NUMBER], where two residents resided, the call light pull cord in the resident's bathroom next to the toilet was missing; -room [ROOM NUMBER], where one resident resided, the call light pull cord wrapped and tied around the grab bar next to the toilet where it could not be easily access and triggered by the resident. Observation on 08/18/2022, at 1:00 P.M., showed the following: -room [ROOM NUMBER], where one resident resided, the call light next to the resident's toilet was missing the call light cord; -room [ROOM NUMBER], where one…

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 give written information to the resident and/or resident's representative of the facility's bed hold policy for two residents (Residents #1 and #14) who were transferred to the hospital. The facility census was 31. Record review showed the facility did not provide a bed hold policy. 1. Record review of Resident #14's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 2/08/2021; -Diagnoses included cerebral infarction (lack of adequate blood supply to the brain), malignant neoplasm of unspecified part of left bronchus or lung (abnormal number of damaged cells that grow in the lung), Type II diabetes (impairment in the way the body regulates and uses sugar as fuel), hemiplegia (condition caused by brain damage or spinal cord injury that leads to paralysis), atrial fibrillation (irregular and often very rapid heart rhythm), and acute kidney failure (when kidneys suddenly become unable to filter waste products from your blood); -Resident had a guardian. Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff administered medications with an error rate of less than 5% when staff made two errors out of 27 opportunities, resulting in an error rate of 7.41%, affecting two residents (Residents #14 and #18). The facility census was 31. Record review of the facility policy, titled Kwik Pen Policy, undated, showed the following: -Priming the insulin pen means removing the air from the needle and cartridge that may collect during normal use and ensures the pen is working correctly; -Prime before each injection with 2 units. Record review of the Novolog Flex Pen (a fast-acting insulin) manufacturer's guidance, dated 3/2021, showed the following: -Before each injection small amounts of air may collect in the cartridge during normal use; -To avoid injecting air and to ensure proper dosing, -Prime (referred to as an air shot) the flex pen before each injection; -Turn the dose selector to select two units; -Hold the flex pen with the needle…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure all residents were free from significant medication errors when staff administered insulin (medication used to help control blood sugar levels) without priming the insulin pens prior to administration per manufacture recommendations and standards of practice for two residents (Residents #14 and Resident #18). The facility census was 31. Record review of the facility policy, titled Kwik Pen Policy, undated, showed the following: -Priming the insulin pen means removing the air from the needle and cartridge that may collect during normal use and ensures the pen is working correctly; -Prime before each injection with 2 units. Record review of the Novolog Flex Pen (a fast-acting insulin) manufacturer's guidance, dated 3/2021, showed the following: -Before each injection small amounts of air may collect in the cartridge during normal use; -To avoid injecting air and to ensure proper dosing, -Prime (referred to as an air shot) the flex…

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.