Ascend At Aurora

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. This failure could potentially place all residents at risk of infection. The facility census was 60. Review of the facility's policy, titled 'Infection Prevention and Control Program', dated 2019, showed the following: -The primary mission is to establish and maintain an Infection Prevention and Control Program (IPCP) designed to provide a safe, sanitary and comfortable environment and to help the development and transmission of communicable diseases and infections; -It is the policy that this facility's IPCP is based upon information from the facility assessment and follows national standards and guidelines to prevent, recognize, and control the onset and spread of infection whenever possible; -The IPCP includes a system for preventing, identifying, reporting, investigating…

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 maintain a facility temperature range of 71 to 81 degrees Fahrenheit (F) and at a comfortable level of the residents in resident rooms and common areas accessible to residents affecting ten residents (Residents #160, #14, #52, #25, #50, #32, #31, #41 ,#35, and #45) out of a sample of 26 residents. The facility census was 60. Review showed the facility did not provide a policy regarding facility heating and cooling system or monitoring of facility temperature for resident comfort. 1. Review of the National Weather Service (website weather.gov) showed on 04/07/24 the high temperature measured 71.6 degrees F. 2. Review of Resident #160's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by the facility), dated 04/08/24, showed the following: -admission date of 03/27/24; -Cognitively intact; -Diagnoses included multiple sclerosis (MS - a long-lasting (chronic) disease of the central nervous system, that impacts the…

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

Based on interview and record review, the facility failed to follow their abuse prevention policy of screening all staff at hire when the facility failed to request a Criminal Background Checks (CBC) or Family Care Safety Register (FCSR - a database that can provide CBC along with other background checks) check prior to one staff member's (Licensed Practical Nurse (LPN) D) contact with residents. A sample of 10 hired employees was reviewed in a facility with a census of 60. Review of the facility's Abuse Prevention Policy, dated 2021, showed the following: -The facility's abuse prohibition program includes the following seven components: screening, training, prevention, identification, investigation, protection and reporting/response; -Screening: The facility will not knowingly employ individuals who have been found guilty of abusing, neglecting or mistreating residents or misappropriating their properties; -All employees will have criminal background checks, state and federal required checks, employment reference checks (previous and current), and license/certification…

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 implement a comprehensive person-centered care plan that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for all residents when staff failed to care plan oxygen use for one resident (Resident #2), failed to care plan smoking safety for one resident (Resident #160), and failed to care plan wound care for one resident (Residents #259). A sample of 26 residents was reviewed in a facility with a census of 60. Review of facility's policy titled, Care Planning - Interdisciplinary Team, dated 02/2021, showed the following: -To assess each resident's strengths, weaknesses, and care needs using the Minimum Date Set (MDS - a federally mandated assessment instrument completed by facility staff); -To use this assessment data to develop a comprehensive plan of care for each resident that will assist resident in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to care plan use of side rails and failed to obtain informed consent for use of side rails for two residents (Resident #6 and #12), and failed to complete gap measurements for installed side rails for three residents (Resident #6, #12, and #23) of a sample of four residents. The facility census was 60. Review of the facility's policy titled, Proper Use of Side Rails, revised December 2016, showed the following: -The purpose of these guidelines is to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms; -Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of resident's; -An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include 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 observation, interview, and record review, the facility failed to ensure food was prepared in a form to meet residents' needs when staff failed to prepare pureed food to the proper consistency in accordance with professional standards for one resident (Resident #26) out of four residents on a pureed texture diet. The facility census was 60. Review of the facility's policy titled, Meal production - Menu, undated, showed pureed food should not be thinner than pudding or thicker than mashed potatoes. 1. Review of Resident #26's face sheet (resident's information at a quick glance) showed the following: -admission date of 04/03/20; -Diagnoses included senile degeneration of the brain (older individuals who suffered from cognitive decline, particularly memory loss), anxiety, and vitamin A deficiency. Review of the resident's April 2024 Physician Order Summary report showed the following: -An order, dated 03/22/23, for regular diet, pureed texture. Do not change order per physician. Review of the resident's care plan, updated 12/29/23, showed the following: -The resident had a…

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

Based on record review and interview, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to a hospital, including the reasons for the transfer, for two residents (Resident #21 and #160), out of a sample of 26 residents. The facility census was 60. Review of the facility's document titled, Notification of Transfer or Discharge, undated, showed the following fields to be completed by facility staff: -Date of transfer, date of notice, resident name, and representative name; -Missouri Ombudsman office, address, and phone number; -You are hereby notified of our intent to transfer or discharge the above named resident for the following reason; -Name and address of location which resident will be transferred or discharged to; -Notice to resident regarding right to appeal transfer or discharge; -Person completing transfer/discharge notice; -Person delivering written notice of transfer/discharge and method of delivery. 1. Review of Resident #160's face sheet showed the following information: -admission date of 03/27/24;…

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

Based on interview and record review, the facility failed to give information to the resident and/or resident's representative of the facility's bed hold policy when two residents (Residents #21 and #160) were transferred to the hospital, out of a sample of 26 residents. The facility census was 60. Review of the facility provided policy, dated February 2014, Bed Hold Policy & Agreement Form, showed the following: -To establish policy and procedure for facility to notify the resident and/or responsible party of the Bed Hold Policy and Agreement to Pay Charges for Bed Hold; -The bed hold agreement is to be obtained for each occurrence - hospital or therapeutic leave; -When hospital or therapeutic leave is reported on the midnight census, the business office will notify the resident and/or responsible party to sign the bed hold agreement; -The business office will address weekend or holiday transfer on the next business day; -When the resident goes to the hospital or out of the facility for overnight visitation the bed may be held by paying the rate as identified in the bed 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 interview and record review, the facility failed to ensure all dialysis residents received services consistent with professional standards of practice when staff failed to routinely communicate and collaborate with the dialysis (a process of filtering and removing waste products from the bloodstream when the kidneys can no longer sufficiently do so) center after appointments for one resident (Resident #47) out of a sample of two residents. The facility census was 60. Review of the facility's policy titled Dialysis Communication, dated 02/2021, showed the following: -It is the policy of the facility to communicate openly and effectively with any provider of dialysis for a resident of the facility; -The Director of Nursing (DON) or designee will contact dialysis unit to establish the communication and explain the facility will be sending a communication form that will facilitate the sharing of resident information surrounding dialysis; -A dialysis communication form will be used to send information to and from the facility to the dialysis center and back; -The nurse in charge…

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 all residents received behavioral health care and services to maintain the highest practical psychosocial well-being when the facility failed to care plan and implement resident specific interventions for one resident (Resident #259) who exhibited signs and symptoms of depression. The facility failed to have social services follow-up with the resident when the resident expressed signs of possible depression. The facility census was 60. Review showed the facility did not provide a behavioral health policy. 1. Review of Resident #259's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 03/18/24; -Diagnoses included chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease the causes obstructed airflow from the lungs), congestive heart failure (CHF - a long-term condition in which the heart can't pump blood well enough to meet the body's needs), and encounter for palliative care. Review of a preadmission hospice…

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

Based on interview and record review, the facility failed to ensure as needed (PRN) orders for psychotropic medications were limited to 14 days when one resident (Resident #9) had an ongoing order for a psychotropic medication with no physician review and justification. The facility census was 60 residents. Review of the facility's policy Psychotropic Medication Use, dated 02/2021, showed the following: -Residents will only receive psychotropic medications when necessary to treat specific conditions which they are indicated and effective; -Gradual dose reductions of psychotropic medications will be done as outlined per federal regulations. (The policy did not address requirements for psychotropic PRN orders.) 1. Review of Resident #9's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 01/05/23; -Diagnoses included anxiety disorder and major depressive disorder. Review of the resident's Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 03/04/24,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed ensure all resident pressure ulcers received treatment consistent with standards of practice to prevent possible infection when staff failed to to utilize appropriate infection control measures during wound care for one resident (Resident #1) with two pressure ulcers, one stage 4 pressure ulcer (a full thickness tissue loss wound with exposed bone, tendon, or muscle) and one stage 3 pressure ulcer (a full thickness tissue loss wound potentially extending to the subcutaneous fat layer), when the nurse failed to wash hands and change gloves at appropriate times during observed wound care. The facility census was 65. Review of the facility policy titled, Infection Prevention and Control Program, dated 2019, showed the following: -To establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases 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 maintain a sanitary environment when the kitchen floors in a clean manner when the floors and a drain in front of the tilt skillet were not cleaned. The facility census was 58. Record review of the Nutrition Services for Department Sanitation guideline, revised on January 2021 showed: -The purpose was to ensure a clean and sanitary work environment; to promote and protect food safety; and to maintain compliance with Federal, State, and Local guidelines and regulations governing food sanitation and safety;. -Sanitation shall be maintained in a manner to support procedures for Food Safety. Staff shall be responsible for daily and weekly cleaning assignments as determined by the Dietary Manager and/or his/her designees; -Cleaning assignments shall include all equipment, storage areas, walls, floors and refrigeration units; -Cleaning equipment condensers, lighting fixtures, vents, etc. shall be completed by the Maintenance Department as determined by the Administrator. 1. Observation on 5/2/22, at 10:37 A.M., of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident's choice of code status (the level of medical interventions a resident wishes to have if their heart or breathing stops) was clearly and consistently documented throughout the resident's medical record for three residents (Resident #3, Resident #45 and Resident #105). The facility census was 58. Record review of the facility's policy titled, Advance Directives, dated [DATE], showed the following: -Prior to or upon admission of a resident to the facility, the Social Services Director (SSD) or designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives; -Information about whether or not the resident has executed an advance directive shall be placed the medical record; -The plan of care for each resident will be consistent with his or her…

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 keep residents who resided in the special care unit (SCU) free from possible harm by not securing hazardous chemicals and other hazardous items and by allowing resident access to a coffee pot with an external hot water spout. Thirteen residents resided on the SCU and the facility census was 58. 1. Record review showed the facility did not provide a policy related to securing hazardous chemicals. Record review of the Safety Data Sheet (SDS - a document that lists information relating to occupational safety and health for the use of various substances and products) for Provon Perineal Wash, dated 7/26/94, showed the following: -May cause eye irritation or gastric upset; -Keep out of reach of children. RecordreviewoftheSDSforGladeSprayLavenderandPeachBlossom revised2/26/15, showedthefollowing -Flammableaerosol -Containedgasunderpressure Mayexplodeifheated -Avoidcontactwithskin eyesandclothing RecordreviewoftheSDSforProConSystemsTurquoise3,…

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 obtain written consent for side rail use, failed to complete a documented side rail assessment, failed to monitor and measure bed rails for risk of entrapment , failed to obtain physician orders for use of side rails, and failed to complete a risk versus benefits side rail assessment for four residents (Resident #15, #27, #38 and #40). The facility census was 58. Record review of the facility's policy titled Proper Use of Side Rails, reviewed 01/2017, showed the following: -Side rails are only permissible if they are used to treat a resident's medical symptoms or reason for using side rails; -An assessment will be made to determine the resident's symptoms or reason for using side rails; -The use of side rails as an assistive device will be addressed in the resident care plan; -Less restrictive interventions will be incorporated in care planning; -Documentation will indicate if less restrictive approaches are not successful, prior 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 observation, interview, and record review, the facility failed to ensure food items were protected from possible contamination when the Special Care Unit (SCU) that held snacks and drinks for the residents was kept clean. The facility's census was 58. 1. Observation on 5/4/22, at 12:19 P.M., of the refrigerator in the SCU that held snacks and drinks for the residents showed the following: -Red and brown dried on particles on the middle shelf in the door, the right and left middle shelf, and bottom shelf, inside the drawer on the left inside and bottom pan under the bottom drawers. Observation on 5/5/22, at 7:25 A.M., of the refrigerator in the SCU that held snacks and drinks for the residents showed the following: -Red and brown dried on particles on the middle shelf in the door, the right and left middle shelf and bottom shelf inside, the drawer on the left inside and bottom pan under the bottom drawers. During an interview on 5/5/22, at 9:49 A.M., Certified Nursing Assistant (CNA) A said the following: -Dietary staff cleaned the refrigerator; -The refrigerator not cleaned…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to administer the pneumococcal (pneumonia) vaccine to two residents (Resident #27 and #40), and failed to offer the pneumococcal vaccine to one resident (Resident #35). The facility census was 58. Record review of the facility policy titled, Infection Prevention and Control Manual, Resident Immunizations and Vaccinations-Pneumonia Vaccine Program, showed the following: -It is the policy of this facility that residents will be offered immunizations against pneumococcal disease; -Pneumococcal disease is a serious illness that can cause sickness and even death; -There are two pneumococcal vaccines available for use in the United States, 13 valent pneumoni conjugate vaccine (PCV13) and 23-valent pneumococcal polysaccharide vaccine (PPSV23); -The Advisory Committee on Immunization Practices (ACIP) for the Center for Disease Control (CDC) recommends that the two vaccines be given in a series to immunocompromised adults [AGE] years of age or older; -The ACIP…

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 criminal background checks (CBCs) and 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 two employees (Dietary Aide (DA) F and Licensed Practical Nurse (LPN) G). The facility census was 58. Record review of the facility's Abuse Policy, revised November 2018, showed the following: -The facility will not knowingly employ individuals who have been found guilty of abusing, neglecting or mistreating residents or misappropriating their properties; -All employees will have criminal background checks, state and federal required checks, employment reference checks (previous or current) and license/certification confirmation; -The facility will make reasonable efforts to uncover information about any past criminal prosecutions; -The facility will report any knowledge it has of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide a Preadmission Screening and Resident Review (PASRR - a federally mandated preliminary assessment to determine whether a resident may have a mental illness (MI) or an intellectual disorder (ID), to determine the level of care needed) for one sampled resident (Resident #8) out of a sample of 23 residents. The facility census was 58. Record review showed the facility did not provide a policy regarding the completion of PASRRs. 1. Record review of Resident #8's face sheet (admission data) showed the following: -admitted to the facility on [DATE]; -readmitted to the facility on [DATE] from the hospital; -Diagnoses included unspecified convulsions, essential hypertension (high blood pressure), and unspecified mood (affective) disorder. Record review of the resident's medical record showed staff did not complete the required level one PASSR screening when the resident admitted to the facility. Record review of the resident's care plan, dated 4/18/21,…

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 all residents received care per the facility's policies and procedures and resident's care plan, when staff failed to accurately monitor and document resident bowel movements (BM) resulting in staff not administering laxatives as ordered for one resident (Resident #32). The facility had a census of 55. Record review of the facility's (undated) policy and procedure titled, For Completion (Activities of Daily Living) ADL Flow Sheets, showed the following information: -ADL (activities of daily living - dressing, grooming, bathing, eating, and toileting) Flow Sheets will be completed on each resident to ensure continuity and accuracy of care given to each resident; -The nursing assistant assigned to each hall will be responsible for documenting on the ADL Flow Sheet by the end of each shift; -The nursing assistant will be responsible for documenting the bowel movement section on the ADL Flow Sheet; -Any outside contracted services including hospice staff, therapy, etc, qualified to assist residents to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to document a discharge summary with information regarding discharge for one resident (Resident #53). The facility census was 58. Record review of the facility's policy titled, Discharge Summary and Plan, reviewed 1/2017, showed the following: -The discharge plan will include resident and family/caregiver education needs and will initiate or maintain collaboration between the nursing facility and other post-acute care providers to support the resident's transition to community living. The discharge plan, instructions, and summary provides a recapitulation (an act or instance of summarizing and restating the main points of something) or summary of the resident's stay. 1. Record review of Resident # 53's face sheet (admission data) showed the following information: -admission date of 1/18/22; -discharge date [DATE]; -Diagnoses included major depressive disorder, acute respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain…

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, facility staff failed to use clean/asepetic technique while performing physician ordered wound care to a diabetic ulcer for one resident (Resident # 41) and failed to apply physician ordered tubigrips (elastic tubular bandages) to one resident's (Resident #17's) legs in a facility with a census of 58. Record review of the facility protocol titled, Treatment Options, revised 4/2018, showed the following: -Chronic wound should be treated using clean (aseptic) treatment technique. 1. Record review of Resident #41's face sheet showed: -admission date of 3/15/22; -Diagnoses included cerebrovascular disease, hemiplegia (paralysis to one side of body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting the left dominant side, type 2 diabetes mellitus (affects how body process sugar), peripheral vascular disease (a slow and progressive circulation disorder), personal history of diabetic foot ulcer, muscle weakness, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to use clean/aseptic (free from contamination) technique to help prevent possible infection while performing physician ordered wound care to a pressure ulcer for one resident (Resident #43) in a facility with a census of 58. Record review of the facility protocol titled, Treatment Options, revised 4/2018, showed the following: -Chronic wound should be treated using clean (aseptic) treatment technique. 1. Record review of Resident #43's face sheet showed: -admitted to the facility on [DATE]; -Resident on hospice services; -Diagnoses included muscle weakness, schizophrenia (mental disorder in which people interpret reality abnormally), and adult failure to thrive. Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 3/23/22, showed the following: -Severe cognitive impairment; -Totally dependent on staff for assistance with bed mobility, transfers, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to consistently provide restorative services, as recommended by therapy, for two residents (Resident #40 and #45). The facility census was 58. Record review of the facility's (undated) policy titled Restorative Nursing Policy and Procedure showed the following: -It is the policy of this facility to provide restorative nursing which promotes the resident's ability to adapt and adjust to living as independently and safely as possible. Restorative nursing focuses on achieving and/or maintaining optimal physical, mental, and psychological function of the resident. The restorative nurse, restorative nurse aide (RNA), along with the interdisciplinary team (IDT), will determine what programs will be initiated for the residents; -Restorative nursing services are provided by RNA, certified nursing assistants (CNA), and other individuals trained in restorative techniques, under the supervision of a licensed nurse; -Screen residents using restorative…

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, the facility failed to ensure all residents received proper treatment and services for their psychosocial well-being when staff did not update one resident's (Resident #1) care plan and implement new interventions and monitoring after the resident made suicidal comments and had suicidal ideations. The facility census was 58. Record review of the facility's policy titled Behavioral Assessment, Intervention and Monitoring, reviewed 1/2017, showed the following: -As part of the initial assessment, staff will identify individuals with a history of impaired cognition, altered behavior, or mental illness; -As part of the comprehensive assessment, staff will evaluate, based on input from the resident, and representative, review of medical record and general observations the resident's pattern of cognition, mood and behavior; the resident's method of communicating things like pain, hunger, thirst and other physical discomforts; and the resident's responses to stress, fatigue, fear,…

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 a medication regimen free from unnecessary medications when the facility failed to implement gradual dose reductions (GDR-a step wise 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) for one resident (Resident #4). The facility census was 58. Record review of the facility's policy titled Consultant Pharmacist Services Provider Requirements, dated 6/1/18, showed the following: -Specific activities that the consultant pharmacist performs includes, but is not limited to: reviewing the medication regimen (medication regimen review) of each resident at least monthly, or more frequently under certain conditions (e.g., upon admission or with a significant change in condition) as notified by facility, incorporating federally mandated standards of care in addition to other applicable professional standards as outlined in the procedure for medication regimen review, and documenting the review and findings in 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.

Based on observation, interview, and record review, the facility failed to ensure all residents were free form significant medication errors when staff failed to monitor resident bowel movements (BM) resulting in staff not administering laxatives as ordered for two residents (Resident #22) and (Resident #32). The facility had a census of 58. Record review of the facility's (undated) policy and procedure titled, For Completion ADL Flow Sheets, showed the following information: -ADL (activities of daily living - dressing, grooming, bathing, eating, and toileting) Flow Sheets will be completed on each resident to ensure continuity and accuracy of care given to each resident; -The nursing assistant assigned to each hall will be responsible for documenting on the ADL Flow Sheet by the end of each shift; -The nursing assistant will be responsible for documenting the bowel movement section on the ADL Flow Sheet; -Any outside contacted services including hospice staff, therapy, etc, qualified to assist residents to the toilet will need to contact the charge nurse or nursing assistant…

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 special equipment for one residents (Residents #5) who the facility identified as needing special equipment to assist with eating. The facility census was 58. Record review showed the facility did not provide a policy related to adaptive equipment. 1. Record review of Resident #5's face sheet (a document that gives a patient's information at a quick glance) showed the following: -admission date of 7/6/20; -Diagnoses included legal blindness, anxiety, and depression. Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 4/14/22, showed the following: -Severe cognitive impairment; -Severely impaired vision with no corrective lenses; -Required no assistance from staff for eating. Record review of the resident's care plan, revised 4/14/22, showed the following: -The resident was blind and had prosthetic eyes; -The resident had potential…

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 staff failed to ensure 100% of the staff had been fully vaccinated for COVID-19 (a highly contagious virus that causes serious illness or death) or granted a qualifying exemption, when one contracted staff member (Employee R) did not have the required documentation for a medical exemption. The facility failed to fully implement their Staff Vaccination Policy for COVID-19 by failing to ensure all unvaccinated staff followed facility policy and took necessary precautions to help mitigate the spread of COVID-19 by properly wearing N95 (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) or KN95 (a mask similar to the N95, but it has ear loops and is made to meet Chinese standards for medical masks) mask. The facility census was 58. 1. Record review of the facility's COVID-19 policy titled COVID-19 Universal Vaccination, updated 3/24/22, showed the following: -To establish…

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 respond promptly to the toileting and bathing needs for five residents (Residents #7, #15, #45, #46 and #50) out of a selected sample of 24 residents. The facility census was 53. Record review of the facility's policy titled Answering the Call Light, dated October 2010, showed the following: -Answer the resident's call lights as soon as possible; -Listen to the resident's request; -Do what the resident asks of you, if permitted; -If you have promised the resident you will return, do so promptly; -If assistance is needed, turn on the call light to summon help. 1. Record review of Resident #7's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission dated 7/12/18; -Diagnoses included quadriplegia (paralysis caused by illness or injury to a human that results in the partial or total loss of use of all their limbs and torso) and flaccid neuropathic bladder (lack of bladder control due 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 observation, interview, and record review, facility staff failed to maintain one resident's (Resident #7) dignity by failing to properly cover a urinary catheter (a sterile tube inserted into the bladder to drain urine) bag. A sample of 24 residents was selected for review. The facility census was 53. Record review for the facility's policy titled Catheter Care, dated 10/1/18, did not show reference or guidance to staff regarding covering catheter bags to provide dignity for the resident. 1. Record review of Resident #7's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission dated 7/12/18; -Diagnoses included quadriplegia (paralysis caused by illness or injury to a human that results in the partial or total loss of use of all their limbs and torso) and flaccid neuropathic bladder (lack of bladder control due to nerve damage). Record review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/26/19, showed the following: -Cognitively intact;…

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 provide the facility's bed-hold policy to two sampled residents (Resident #45 and #47) prior to being transferred/discharged to the hospital. The facility census was 53. Record review of the facility's policy titled Bed Hold Policy and Agreement Form, revision dated February 2014, showed the following: -The bed hold agreement is to be obtained for each occurrence of hospital or therapeutic home leave; -When hospital or therapeutic home leave is reported on the midnight census, the business office will notify the resident/responsible party to sign the bed hold agreement; -The business office will address weekend or holiday transfers to the hospital or therapeutic home leave on the next business day. 1. Record review of Resident #45 face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission dated 12/1/2017; -Diagnosis included kidney disease, muscle weakness, and congestive heart failure (CHF - chronic…

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 staff revised one resident's (Resident #6) comprehensive care plan to include the development of pressure ulcers, out of a sample of 24 residents. The facility census was 53. Record review of the facility's policy titled Care Plans, Comprehensive Person-Centered, dated December 2016, showed the residents' care plans will include the following: -Services that are provided to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; -Identified problem areas and treatment goals; -Interventions to aid in preventing or reducing decline in the resident's functional status; -Revision to the care plan when the resident's condition changes. 1. Record review of Resident #6's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission dated 3/8/18; -Diagnoses included pressure ulcer to the sacral (area at base of spine) region, chronic (long term) pain, and diabetes mellitus (a disease that results in too much sugar in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to follow physician's order for laboratory tests for two residents (Resident #7 and #11) and for supplement oxygen for one resident (Resident #7) out of a sample of 24 residents. The facility census was 53. Record review of the facility's policy titled Laboratory and Diagnostic Testing, dated September 2012, showed the following: -The physician will identify and order diagnostic and lab testing based on the resident's needs; -The staff will process test requisitions and arrange for tests to be completed. Record review of the facility's undated policy titled Oxygen Therapy, showed the following: -A physician order will be obtained and followed for oxygen use. 1. Record review of Resident #7's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission dated 7/12/18; -Diagnoses included quadriplegia (paralysis that results in the partial or total loss of use of all limbs and torso) and sleep…

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 medication regimens were free from unnecessary medication when the facility failed to provide rationale to continue an as needed (PRN) psychotropic medication (drugs that alter chemical levels in the brain which impact mood and behavior, used to treat mental illness) past 14 days for one resident (Resident #8) in a selected sample of 24. The facility census was 53. Record review of the facility's policy titled Administering Medications, dated December 2012, showed the following: -If a resident uses PRN medications frequently the physician, interdisciplinary team, and the pharmacist shall reevaluate to determine if there is a clinical reason for the PRN use of the medication ordered. 1. Record review of Resident #8's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission dated 4/26/17; -Diagnoses included stroke, chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), and depression. Record review of the resident's physician'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 observation, interview, and record review, the facility failed to use appropriate infection control procedures to prevent or reduce the risk of spreading bacteria or other infectious causing contaminants when staff failed to use appropriate hand hygiene while performing incontinent care for one resident (Resident #7) with a catheter and failed to perform appropriate wound care for one resident (Resident #6) in a selected sample of 24 residents. The facility census was 53. According to the Center for Disease Control's (CDC) Guideline for Hand Hygiene in Healthcare Settings, 2002, volume 51 showed the following: -The hands are the most common mode of transmitting pathogens (microorganisms); -Clean hands are the single most important factor in preventing the spread of pathogens and antibiotic resistance (infections caused by microorganisms that are resistant to antibiotics) in healthcare settings; -There is substantial evidence that hand hygiene reduces the incidence of infections. Record review of 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.