Blue Springs Wellness & Rehabilitation

Based on observation, interview and record review, the facility failed to label medications with resident's name on the medication container when the box was first opened. The facility census was 84 residents. Review of the facility Medication Storage policy dated September 2018 showed: -The provider pharmacy dispensed medications in containers that met regulatory requirements, included standards set forth by the United States Pharmacopeia (USP). -Medication storage conditions were monitored on a regular basis by the consultant pharmacist and corrective actions were taken if a problem was identified. -The policy did not show where the individual medication container needed to be labeled when the box was labeled. 1. Observation on 3/26/25 at 10:50 A.M. of the 400/500 hall Certified Medication Technician (CMT) medication cart showed: -One Ellipta inhaler (for Chronic Obstructive Pulmonary Disease (COPD process that decreases the ability of the lungs to perform ventilation), which includes chronic bronchitis (an inflammation of the lining of your bronchial tubes) and emphysema (inner…

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 serve pureed (food that has been processed into a smooth, uniform, and pudding-like texture, often by blending, mashing, or straining) food items in the correct texture. This deficient practice had the potential to affect all residents who received pureed diets. The facility census was 84 residents. Review of the Facility Instructions for pureed food items dated 2025, showed: -Any liquid specified in the recipe is a suggested amount of liquid if needed. -Some recipe items will require no liquid added to achieve the desired consistency. -If the product needs thinning, gradually add an appropriate amount of liquid, not water, to achieve a smooth, pudding or soft mashed potato consistency. -If the product needs thickening, gradually add a commercial or natural food thickener (potato flakes or baby rice cereal) to achieve a smooth, pudding or soft mashed potato consistency. 1. Observation and interview on 3/25/25 at 12:46 P.M., showed the test tray contained the pureed hamburger, pureed rice and pureed cream 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 infection control handwashing practice was followed to prevent cross contamination during a gastronomy (which is a surgical opening into the stomach) water flush for one sampled resident (Resident #14); and failed to ensure infection control practices performed hand hygiene between each glove change during care of indwelling Foley Catheter (a urinary bladder catheter inserted through urethra); and failed to ensure to place Personal Protective Equipment (PPE, refers to protective clothing for the eyes, head, ears, hands, respiratory system, body, and feet. To be worn to minimize exposure to a variety of hazards) while providing direct contact care for one sampled resident (Resident #5) who required Enhanced Barrier Precaution (EBP, for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multi-drug-resistant organism status) due to the indwelling Foley catheter…

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 the floors of the following rooms in a clean condition in resident rooms 204, 105, 101, 304, 310, 514, 504, 501, 411, 406, and 407. This practice potentially affected 12 residents. The facility census was 68 residents. 1. Observation on 12/2/24 with the Housekeeping Supervisor showed: - At 12:59 P.M., there was a buildup of cobwebs along the floor and wall area next to the refrigerator in resident room [ROOM NUMBER]. - At 1:01 P.M., there was a buildup of cobwebs in the corners of room [ROOM NUMBER]. - At 1:04 P.M., there was a buildup of dust and debris along the wall in resident room [ROOM NUMBER]. - At 1:05 P.M., there was a buildup of hair and dust along the wall in resident room [ROOM NUMBER]. - At 1:08 P.M., there was a buildup of dust under the bed in resident room [ROOM NUMBER]. - At 1:10 P.M., there was a buildup of dust and cobwebs behind the bed and long the walls at the floor level in resident room [ROOM NUMBER]. - At 1:15 P.M.,…

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 promote and facilitate one sampled resident's (Resident #3) self determination out of four sampled residents. The facility census was 76 residents. Review of the facility's undated Nursing Home Resident's Rights showed: -The law requires nursing home to promote and protect the rights of resident and stresses individual dignity and self-determination. -Right to dignified existence. --Be treated with consideration, respect, and dignity, recognizing each resident's individuality. --Quality of life is maintained or improved. --Exercise rights without interference, coercion, discrimination, or reprisal. -Right to self-determination. --Reasonable accommodation of needs and preferences. --Participate in developing and implementing a person-centered plan of care that incorporates person and cultural preferences. --Choice about designating a representative to exercise his/her rights. --Request, refuse, and/or discontinue treatment. -Right to be fully informed…

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 establish a system of disposition of controlled drugs, when staff failed to sign their initials on the narcotic count sheet and the Medication Administration Record (MAR) after administering narcotic (a variety of substances that dulled the senses and relieved pain) medications to four sampled residents (Residents #1, #2 #3 and #4); and the facility failed to ensure Norco (a combination of 5 milligrams of Hydrocodone and 325 milligrams of Acetaminophen used to relieve moderate to severe pain) was secured from loss; and to maintain a narcotic count sheet to show the administration of Norco doses for one sampled resident (Resident #1). The facility census was 76 residents. Record review of the facility's Policy entitled Controlled Substances, revised on 10/07 and reviewed on 3/16/23, showed: Policy: It was the policy of the facility that all drugs listed as schedule II drugs were subject to specified handling, storage, disposal and record keeping. Responsibility: All Licensed Nurses. Procedure: -At the time a Controlled…

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 8. Record review of Resident #48's Face Sheet showed he/she was admitted on [DATE], with diagnoses including failure to thrive, arthritis, pain and vitamin D deficiency. Record review of the resident's quarterly MDS dated [DATE], showed the resident: -Was alert and oriented -Was dependent on staff extensively for bathing, dressing, grooming and toileting. Observation on 7/19/23 at 8:55 A.M., showed the resident was sitting up in his/her specialized wheelchair, dressed for the weather. At this time CNA E and CNA F came into the resident's room and without washing or sanitizing their hands, both CNA's put on gloves. The following occurred: -CNA E and CNA F began to attach the sling to the full body lift. CNA E operated the lift while CNA F monitored the resident and positioned the resident in his/her bed. -CNA E then removed his/her gloves, washed his/her hands then removed the lift from the room. -CNA F removed the sling from under the resident, obtained briefs from the residents drawer, pulled 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 have a process to ensure the antibiotic (an antimicrobial [an agent that kills microorganisms or stops their growth] medication) ordered for each resident was appropriate for the treatment of the infection, that excessive antibiotics were not used, and to monitor antibiotic use trends. This had the potential to affect all residents at the facility. The facility census was 77 residents. Review of the facility's policy, dated 3/20/23, titled Assessment of Infections and Antimicrobial Usage showed: -Assessing antimicrobial use was essential for determining antimicrobial trends. -Staff were to perform a monthly review of antibiotics ordered and the clinical documentation for why the medication was ordered. -Staff were to review clinical documentation for documented signs and symptoms of infection for each resident prescribed an antibiotic. -Staff were to document whether testing was performed and the results. -After completing the above for all residents on an antibiotic, staff were to summarize the information…

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 the main kitchen area free from roaches and to maintain the facility free from numerous flies, which were present throughout the facility. This practice potentially affected all residents. The facility census was 77 residents. 1. Observations on 7/17/23 at 9:27 A.M., showed roaches in the chemical storage room and a roach which crawled on the ceiling over the corridor to back exit door from the kitchen. Observations on 7/20/23, showed: -At 6:51 A.M., showed one roach crawling on wall at the lower level of steam table. -At 7:01 A.M., showed another roach which crawled on the door jamb of door between kitchen and assist dining room. -At 7:05 A.M., one roach crawled on wall next to ice tea making machine. -At 7:07 A.M., four roaches crawled on wall behind ice tea machine. During an interview on 7/20/23 at 7:08 A.M., Dietary [NAME] (DC) B said the facility is old and there have been and were roaches in the kitchen. During an interview on 7/20/23 at…

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 the ceiling fans in the south dining room free form a buildup of dust; to maintain restroom ceiling vents free of dust inside the vents in resident rooms 401, 507, 308, 306 and 302; to maintain resident use fans free of a heavy buildup of dust in resident room [ROOM NUMBER]; to maintain the ceiling fan in the therapy office free from a heavy buildup of dust; and to maintain the commode seat in the restrooms of 208, 104 and 102. This practice potentially affected at least 50 residents who resided in or used those areas. The facility census was 77 residents. 1. Observation on 7/17/23 at from 12:33 P.M. through 12:52 P.M., showed a heavy buildup of dust on the blades of the ceiling fans over the south dining room where 24 residents ate their lunch meal. During an interview on 7/17/23 at 12:55 P.M., the Housekeeping Supervisor said the fans are cleaned every two days, but the cleaning cloth may not get the dust from the fan blades like it should. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure care plans were up to date and reflected the resident's current status for four sampled residents (Resident's #6, #25, #11 and #4) out of 18 sampled residents. The facility census was 77 residents. The facility's policy titled Comprehensive Care Planning dated 7/20/22 showed: -It is the policy to comprehensively assess and periodically re-asses each Resident admitted to the facility. -The results of the resident assessment shall serve as the basis for determining each resident's strengths, needs, goals, life history, and preferences to develop a person centered comprehensive care plan. -Care plans were to include the resident's medical, nursing, physical, mental, and psychological needs. -Each resident's comprehensive care plan will describe the services that are furnished to attain or maintaining the resident's highest practicable physical, mental, and psychosocial well-being. -The care plan shall be revised as necessary when the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation interview and record review, the facility failed to ensure physician's orders for oxygen were transcribed to the physician's order sheet for two sampled residents (Resident #179 and #11) and to ensure oxygen equipment such as nasal cannulas (a lightweight tube which on one end splits into two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows), tubing and respiratory suction equipment was stored in a sanitary condition for four sampled residents (Resident #17, #179, #11, and #25) out of 18 sampled residents and seven supplemental residents. The facility census was 77 residents. Review of the facility's Oxygen Storage and Assembly policy and procedure dated 01/2002, showed: -The purpose was to properly store and assemble oxygen tanks and accessories in a safe and correct manner. -It showed the equipment included the nasal cannula, face mask and tubing and a plastic or cloth bag for the cannula or mask. -The policy did not show how the nasal cannula, face…

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 ensure the pharmacist's monthly medication recommendations were addressed in a timely manner for one sampled resident (Resident #25) out of 18 sampled residents. The facility census was 77 residents. Review of the facility's policy, dated 11/28/16, titled Medication Regimen Review (MRR) showed: -Facility staff were to ensure the attending physician, Medical Director, and Director of Nursing (DON) were provided with copies of each residents' MRR. -The attending physician was to document in the resident's chart that the identified irregularity had been reviewed and what, if any action, had been taken. -If the attending physician decided not to make changes per the pharmacist's recommendations, the rationale was to be documented in the resident's chart. -The facility was to alert to attending physician when MRRs were not addressed in a timely manner. -The physician was to address all recommendations no later than 30-60 days after the recommendations were…

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 refrigerator was double locked which had narcotics (controlled substances) stored in it; and to ensure a crash cart (a cart used for medical emergencies) was locked. The facility census was 77 residents. Review of the facility's policy titled Controlled Substances dated [DATE] showed schedule II drugs (drugs with a high potential for abuse, with use potentially leading to severe psychological or physical dependence) were to be kept under two separate locks requiring two separate keys. A policy related to crash carts was requested and not received at time of exit. 1. Observation of the locked unit's medication room on [DATE] at 2:00 P.M. showed: -The medication refrigerator door was unlocked. -The medication refrigerator contained three vials of Lorazepam (Ativan- a medication used to treat anxiety) two milligrams (mg)/ milliliters (ml). -The medication refrigerator contained three boxes of Lorazepam Oral Concentrate two mg/ml.…

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 temperatures of hot foods on room tray meals, were maintained at or close to 120 ºF (degrees Fahrenheit) and the facility failed to ensure that seasonings and condiments were available for residents who want to use them. This practice potentially affected five residents on the 200 Hall and at least 12 residents who resided on on the 400 and 500 Hall. The facility census was 77 residents. 1. Review of Resident #27's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning) dated 5/15/23 identified the resident as cognitively intact with a Brief Interview for Mental Status (BIMS-an assessment tool that shows a score between 3 of 15 which shows the resident's mental status, which helped to determine the resident's attention, orientation and ability to register and recall new information and these items are crucial factors in care planning decisions) score of 15 of 15. During 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 observation and interview, the facility failed to maintain the fan vent covers of the freezer free from a dust buildup, to ensure there was not chipping paint on the range hood; to prevent a buildup of dust and grease on the light fixtures over the food preparation area; to maintain the ceiling vents in the south kitchenette and in the main kitchen free of a heavy dust buildup inside the vents; to maintain the outflow vents of the air conditioner free of a heavy dust buildup and to maintain the floor of the south kitchenette free from food crumbs and debris. This practice potentially affected all residents who ate food from the kitchen. The facility census was 77 residents. 1. Observation of the main kitchen on 7/17/23 from 8:58 A.M. through 12:30 P.M., showed: -A buildup of dust on the fan vent covers in the walk-in refrigerator. -A buildup of dust and grease on the light fixtures over the food preparation area. -The presence of chipping paint on the range hood. -A buildup of dust on the outflow vent of the window unit air conditioner. Observation of the South Unit…

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 the 400 Hall, 500 Hall and 100 Hall shower rooms in good repair to prevent water from flowing into the room adjacent to the 500 Hall shower room; to maintain the following non-resident areas in a sanitary manner: the floor technician's office and under the vending machines; and to maintain the 3 compartment sink in the kitchen in good repair. This practice potentially affected at 50 residents who resided in or used those areas. The facility census was 77 residents. 1. Observation on 7/18/23 at 2:46 P.M., showed a pool of water flowed from the 500 Hall shower room which was the adjoining room to the room (room [ROOM NUMBER]). The water created a standing pool of water around the chairs closest to the 500 Hall shower room. During an interview on 7/18/23 at 3:14 P.M., Certified Nurse's Assistant (CNA) K said the water has flowed from the shower room to room [ROOM NUMBER], with that much capacity at least three times within the last two months when…

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 adequate ventilation to remove excess heat from the kitchen, and to have ventilation which included negative air flow in the 400 Hall shower room, the 400 Hall medication room, the south hall soiled utility room the 500 Hall shower room, the 300 Hall shower room, the 100 Hall shower room, and the restroom of resident room [ROOM NUMBER] This practice potentially affected 61 residents who resided close to or use those area. The facility census was 77 residents. 1. Observation on 7/17/23 at 11:19 A.M., showed the temperature of the kitchen was 83 ºF (degrees Fahrenheit). During an interview on 7/17/23 at 11:21 A.M., Dietary [NAME] (DC) A said the kitchen felt hot to him/her. During an interview on 7/17/23 at 11:24 A.M., the Dietary Manager (DM) said sometimes, it got stuffy in the kitchen and he/she would notify the Maintenance Director (MD). Observation on 7/17/23 at 11:35 A.M., showed the MD checked on the vent that was supposed to remove the air…

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 a system was in place for tracking the Certified Nursing Assistant's (CNAs) 12 hours of Continuing Education Units (CEU); and to provide documentation of staff training records and annual dementia care training for 2022 for five sampled staff. The facility census was 77 residents. The facility did not provide a policy related to ongoing staff training by the time of exit. 1. Review of all facility staff in-services attendance sheets showed the following in-services topics were completed from 7/25/22 to 4/25/23: -On 7/25/22 heat safety and signing Medication Administration Records (MAR)/Treatment Administration Record (TAR). -On 10/25/22, fire drills are serious. -On 11/10/22, safe resident handling. -On 11/25/22, abuse. -On 2/25/23, resident rights and use of mechanical lifts. -On 3/7/23, door alarms. -On 3/10/23 smoking policy. -On 3/10/23 Nurses & Certified Medication Technician (CMT) Antibiotic use. -On 4/25/23 isolation. -NOTE: Did not include dementia care training sign in sheets or documentation of dementia…

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, showed the facility failed to ensure the dignity of one sampled resident (Resident #17) was protected by failing to ensure the resident's catheter (tube known as a urinary catheter is inserted into the bladder through the urethra to allow urine to drain from the bladder for collection) bag was in a privacy bag out of 18 sampled residents. The facility census was 77 residents. 1. Review of the Resident #17's Face Sheet showed he/she was admitted on [DATE], with diagnoses including spinabifida (a birth defect in which a developing baby's spinal cord fails to develop properly), high blood pressure and neurogenic bladder (to lack bladder control due to a brain, spinal cord or nerve problem). Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 6/5/23, showed the resident: -Was alert and oriented. -Needed extensive to total assistance with transferring, bathing,…

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 ensure a transfer notice was sent to the Ombudsman (individuals who help residents in long-term care facilities maintain and improve their quality of life by helping ensure their rights are preserved and respected) when one sampled resident (Resident #36) was transferred to the hospital out of 18 sampled residents. The facility census was 55 residents. A facility policy related to Ombudsman notification was requested and not received at the time of exit. 1. Review of Resident #36's face sheet showed he/she re-admitted to the facility on [DATE] with the following diagnoses: -Unspecified Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses) unspecified severity with behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. -Personal history…

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 ensure the resident and/or responsible party were informed of and signed a bed hold for two sampled residents (Resident #16 and Resident #36) out of 18 sampled residents. The facility census was 77 residents. Review of the facility's Bed Hold policy and procedure dated showed: -Upon leaving the facility for admission to a hospital or for therapeutic leave, a resident shall be guaranteed a bed in this facility upon return if the resident's condition is such that he/she is appropriate for the level of care provided by the facility and a Medicaid eligible resident was not in the hospital or on leave for more than 10 consecutive days; or the Medicaid resident or responsible party has agreed to pay the public aid rate for days in excess of the 10 days, or a private pay resident has insured a hold on a bed through reimbursement at the current private pay rate. -The resident, resident's family or legal representative will be given the appropriate Notice of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure a Quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) was accurate and submitted on time for one sampled resident (Resident #25) out of 18 sampled residents. The facility census was 77 residents. Review of the facility's policy, dated 11/1/17, titled Comprehensive Assessments/MDS showed: -Staff were to complete a Quarterly MDS on each resident within 92 days of the previous MDS. -Staff were responsible for ensuring the MDS was accurate. 1. Review of Resident #25's face sheet showed he/she was admitted on [DATE] with a diagnoses of acute (short term) and chronic (long term) respiratory failure (a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide). Review of the resident's MDS submissions showed: -A Quarterly MDS dated [DATE]. -No further MDS's submitted. -NOTE: At time of exit, it had been 96 days since the last Quarterly MDS had been…

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 baths were given and documented twice weekly for one sampled resident (Resident #34) and to provide one sampled resident (Resident #4) proper Activities of Daily Living (ADL) care necessary to maintain grooming needs out of 18 sampled residents. The facility census was 77 residents. A policy on ADL care was requested and not received at the time of exit. 1. Review of Resident #34's Face Sheet showed he/she was admitted on [DATE], with diagnoses including spondylosis (arthritis of the spine), Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), history of stroke, diabetes, high blood pressure, history of falls and abnormal gait (balance). Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 5/11/23, showed the resident: -Was alert and oriented. -Needed…

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 to complete and document a comprehensive Weekly Skin Assessment for two sampled residents (Resident #62 and Resident #64) who were high risk and had current treatments for skin breakdown, out of 18 sampled residents. The facility resident census of 77 residents. Review of the facility Policy and Procedure Skin Condition Monitoring revised 3/16/23 showed: -Licensed nursing staff were responsible for providing monitoring, treatment and documentation of any resident with skin abnormalities. -Documentation of the skin abnormality must occur upon identification and at least weekly thereafter until the area were healed. The documentation must include the following: size, shape, depth, odor, color and condition of the tissue. -Treatment and response to treatment. Observe and measure pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with…

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

Based on observation, interview and record review, the facility failed to ensure safe secure storage of cleaning chemicals by leaving the housekeeping keys unsupervised in the door located on memory care unit for over 30 minutes. The facility census was 77 residents. A policy for storage of housekeeping chemical cleaning supplies was requested and not received at the time of exit. 1. Review of Resident #53's Quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 2/18/23 showed: -The resident was severely cognitively impaired. -He/she had wandering behaviors. Observation on 7/19/23 at 11:00 A.M. showed the resident was walking up and down the hallway with his/her head down and would enter the conference room when the door was open. 2. Observation on 7/19/23 at 11:45 A.M. to 12:12 P.M. of the Memory Care Unit housekeeping cleaning supplies storage room (located on the 500 hall) showed: -The lock/unlock of the doorknob had a set keys hanging from the doorknob lock. -With the set of keys in the key hole, was able…

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 maintain the resident's catheter (a tube is inserted into the bladder through the urethra to allow urine to drain from the bladder for collection) below the bladder for two sampled residents (Resident #17 and #11) with a history of urinary tract infections (UTI - an infection of one or more structures in the urinary system); failed to provide catheter care as ordered by the resident's physician and to prevent the catheter drainage bag from coming in contact with the floor without a barrier for one sampled resident (Resident #11) out of 18 sampled residents. The facility census was 77 residents. Review of the resident's Catheter Care policy and procedure dated 3/15/23, showed catheter care is provided daily and as needed to all residents who have an indwelling catheter to reduce the incidence of infection. The policy did not show where the catheter bag placement should be. 1. Review of the Resident 17's Face Sheet showed he/she was admitted…

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 ongoing communication of dietary needs related to assistance while eating; to update the dietary cards; and to include the assistance needed for eating within the care plan for two sampled residents (Resident #36 and Resident #53) out of 18 sampled residents. The facility census was 77 residents. 1. Review of Resident #36's face sheet showed he/she admitted to the facility with the following diagnoses: -Unspecified Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses) unspecified severity with behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. -Personal history of Cerebral Infarction (ischemic stroke- occurs as a result of disrupted blood flow and oxygen to the brain) with residual deficits. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure pneumococcal (a name for any infection caused by bacteria called Streptococcus pneumonia) vaccinations were offered for four sampled residents (Resident #64, #179, #25, and #26) out of 18 sampled residents. The facility census was 77 residents. Review of the facility's policy, dated 1/23/20, titled Immunization of Residents showed: -Staff were to offer all residents vaccinations to aid in the prevention of infectious diseases. -Staff were to obtain proof of pneumococcal vaccinations upon admission. -Staff were to offer the pneumococcal vaccine within 30 days of admission. -Staff were to document all vaccinations on the Immunization Record. 1. Review of Resident #64's admission Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning), dated 5/27/22 showed: -The resident was not up to date on the pneumococcal vaccine. -Staff did not offer the resident a pneumococcal vaccine. 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.

Based on observation, interview, and record review, the facility failed to establish and maintain a comprehensive, facility-specific infection prevention and control program designed to help prevent the development and transmission of waterborne pathogens (a bacterium, virus, or other microorganism that can cause disease), which included the following: a risk assessment to identify where waterborne pathogens could grow and spread, diagrams of which hot water heaters provide hot water to which sections of the facility, testing protocols with acceptable ranges for control measures when control measures in water from the water company were not maintained, how the facility will account for changes in water quality such as water main breaks and construction, and specific actions that would be taken in response to a legionella positive water sample. This deficient practice had the potential to affect all residents and staff who reside in or work in the facility. The facility census was 67 residents with a licensed capacity of 120 residents. Record review of page 3 of Centers for Disease…

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 notify three sampled residents (Residents #61, #50 and #52) who had amounts in their resident trust which exceeded the $4,835.00, which is within $200 of the limit of $5,035.00 limit for required notification to residents to spend down. This practice affected three residents. The facility census was 67 residents. 1. Record review of Resident #61's trust fund yearly statement dated 1/1/22 through 3/31/22, showed the resident had the following balances: -A balance of $9,240.42 on 1/31/22. -A balance of $9,292.56 on 2/28/22. -A balance of $9,342.56 on 3/31/22. 2. Record review of Resident #50's trust fund yearly statement dated 1/1/22 through 3/31/22, showed the resident had the following balances: -A balance of $5,421.39 on 2/28/22. -A balance of $6,987.36 on 3/31/22. 3. Record review of Resident #52's trust fund yearly statement dated 1/1/22 through 3/31/22, showed the resident had the following balances: -A balance of $5,858.68 on 1/31/22. -A balance of $5,910.04 on 2/28/22. -A balance of $5,960.04 on 3/31/22. During 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 maintain a surety bond (a promise to be liable for the debt, default, or failure of another; It is a three-party contract by which one party (the surety or bond company) guarantees the performance or obligations of a second party (the principal (the nursing home) to a third party (the oblige--the residents who are a part of the resident trust)) that was one and one half times the average of the monthly balance of the reconciled bank statements for the resident trust. This practice potentially affected 14 residents who allowed the facility to manage their resident funds. The facility census was 67 residents. 1. Record review of the instructions for determining what a surety bond amount should be, showed: -The monthly reconciled bank statements and the monthly ending petty cash (the amount of cash that the facility keeps to be accessible to the residents) are added together for each of the previous (usually 9-12) months since the last survey. -The total amount of those totals are added together for a grand total. -That grand…

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 Notice of Medicare Non-Coverage (NOMNC) for two sampled residents (Resident #1 and #61) and one supplemental resident (Resident #267) and failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) for two sampled resident (Resident #1 and #61) who remained in the facility but were discharged from Medicare part A services out of three residents sampled for beneficiary notices. The facility census was 67 residents. The facility did not have a policy regarding SNF ABNs or NOMNCs. Record review of the undated Form Instructions for the NOMNC (Centers for Medicare and Medicaid Services Survey and Certification (CMS)-10123 showed the NOMNC must be delivered at least two calendar days before Medicare coverage services end. Record review of the CMS memo (S&C-09-20), dated 1/9/09, showed: -The NOMNC, form CMS-10123 is issued when all covered Medicare services end for coverage reasons; -If the SNF believes on admission or during a resident's stay that Medicare will not pay for skilled nursing or…

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 the mattresses in resident rooms [ROOM NUMBERS] in an easily cleanable condition; to maintain three ceiling fans in the Special Care Unit (SCU) free of a buildup of dust; to maintain the base of two stand-up lifts without cracks; to maintain the ceiling vents in the 300 hall shower room and the restrooms of resident rooms 306, 302, 212, 203, 201, 109, 108, 105, 103, and the north dining room, free of a heavy buildup of dust inside the vents; to maintain the commode seats in the restrooms of resident rooms [ROOM NUMBERS] in an easily cleanable condition; and to maintain the base of two stand-up lifts without cracks. This practice potentially affected at least 40 residents who resided in or used those areas or equipment throughout the facility. The facility census was 67 residents. 1. Observation with the Maintenance Director on 4/4/22 at 10:17 A.M., showed a mattress in resident room [ROOM NUMBER] with an 11 inch (in.) rip which made it 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assess a resident using the quarterly review instrument specified by the State and approved by Centers for Medicare and Medicaid Services (CMS) not less frequently than once every 3 months for nine sampled residents (Resident #31, #9, #34, #32, #27, #47, #45, #7, and #26) out of 17 sampled residents. The facility census was 67 residents. Record review of the facility policy titled Comprehensive Assessment/MDS (MDS - a federally mandated assessment instrument completed by facility staff for care planning) revised 11/1/2017 showed: -The facility would comprehensively asses and periodically reassess each resident admitted to the facility. -The MDS would be re-evaluated quarterly-within 92 days of previous MDS. -The MDS would be transmitted to the Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system as required by Federal Regulation and designated in the Resident Assessment Instrument (RAI) Manual. 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 electronically transmit within 14 days of completion 46 out of 100 Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) assessment and tracking records (entry/discharge records) electronically transmitted from 1/7/22 through 3/8/22. The facility census was 67 residents. Record review of the facility Comprehensive Assessment/MDS policy, revised 11/1/20217 showed: The MDS would be transmitted to the Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system as required by Federal Regulation and designated in the Resident Assessment Instrument (RAI) Manual. Record review of the Long Term Care Facility RAI 3.0 User's Manual, Version 1.17.1, dated October 2019 showed: -Nursing homes are required to submit Omnibus Budget Reconciliation Act (OBRA) required MDS records for all residents in Medicare- or Medicaid-certified beds regardless of the pay source to Centers for Medicaid and Medicare Services's (CMS) Quality Improvement 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 interview and record review, the facility failed to develop individualized care plans describing a need or problem and indicating approaches/interventions to assist the resident in relation to the need or problem for two sampled residents (Resident #29 and #41) and to complete a comprehensive care plan addressing all resident needs within 21 days of admission for one sampled resident (Resident #265) out of 17 sampled residents. The facility census was 67 residents. Record review of the facility's Comprehensive Care Planning policy, revised 11/1/17 showed: -The facility will comprehensively assess and periodically reassess each resident admitted to the facility. The results of this assessment shall serve as the basis for determining each resident's strengths, needs, goals, and preferences to develop a person-centered, comprehensive plan of care for each resident that will describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial…

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

Based on observation and interview, the facility failed to post required nurse staffing information, which included the total and actual hours worked by both licensed and unlicensed staff directly responsible for resident care, per shift on a daily basis and visible for residents, visitors, and staff to view. The facility census was 67 residents. A policy was requested but not received by the facility. 1. Observation on 3/31/22 at 11:36 A.M. showed: -The front lobby area, the front nurses station and area by the administrators office. -There was no staffing posted. Observation on 4/1/22 at 10:58 A.M. showed: -The front lobby area, the front nurses station and area by the administrators office. -There was no staffing posted. Observation on 4/4/22 at 5:40 A.M. showed: -The front lobby area, the front nurses station and area by the administrators office. -There was no staffing posted. Observation on 4/5/22 at 8:38 A.M. showed: -The front lobby area, the front nurses station and area by the administrators office. -There was no staffing posted. During an interview on 4/5/22 at 9:20 A.M.…

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 prepare pureed (food that is prepared into a paste or thick liquid suspension usually made from cooked food that was finely ground) eggs in a manner according to the recipe to be flavorful. This practice potentially affected three residents who had physician's orders for pureed diets. The facility also failed to maintain food on breakfast trays delivered to the Special Care Unit (SCU) at or close to 120 ºF (degrees Fahrenheit) of at least seven residents who were served later in the process of serving. The facility census was 67 residents. 1. Record review of the undated recipe for six servings of pureed eggs, showed: - Six 2 ounce (oz.) servings of scrambled eggs. - 6 fluid oz. of milk. - 1 .5 Tablespoons of food thickener (starch or gel-based additives that make fluids and edibles easier to swallow). Instructions: Remove portions required from the regular prepared recipe and place in a food processor. - Process until fine in consistency.…

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 do or maintain the following: keep the package of bacon in the walk-in fridge covered; maintain the floor of the walk-in fridge free of a buildup of dust and food debris; maintain proper illumination from the light fixtures over the dishwasher area; maintain the top inner part of the ice-machine free of a pink colored slime; maintain the light fixtures in the kitchen free of grease and dust; label a container with the name of what is in the container; and maintain the cutting boards in an easily cleanable condition. This practice potentially affected 65 residents who ate food from the kitchen. The facility census was 67 residents. 1. Observations during the initial kitchen tour on 3/31/22 from 8:56 A.M. through 9:13 A.M., showed: - Uncovered bacon in the walk-in refrigerator. - A buildup of debris on the floor of the walk-in refrigerator. - A buildup of dust in the ceiling vents in the kitchen. - The presence of a pink slime on the top inner part of the ice machine. - The lights at the dishwasher area did 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 label and date food that was brought in from outside sources for residents who resided on the Special Care Unit (SCU) and the Front Halls. This practice potentially affected at least six residents who resided in those areas. The facility census was 67 residents. Record review of the facility's policy entitled Food from Outside Sources/Personal Food Storage, revised on 6/09, 10/14 and 4/17, showed: - It is the policy of facility to obtain food for resident consumption from sources approved or considered satisfactory by Federal, State or local authorities. - All resident have the right to accept food brought to the facility by any visitor(s) and/or food from a facility garden, however the food must be handled in a way to ensure resident safety. - Food and beverages brought in from outside sources, that are to be stored in the facility refrigerators and freezers, will be checked by a dietary staff member. - Any suspicious or obviously contaminated food or beverage will be discarded immediately. - Food 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 the dumpster lids was closed on two different days of the survey. This practice potentially affected the outdoor premises of the facility with the potential of pest harborage. The facility census was 67 residents. 1. Observations on 4/1/22 at 9:53 A.M., 10:22 A.M., 11:58 A.M., and 1:08 P.M., showed the lid to one of the outdoor dumpster's open and not closed. Observations on 4/4/22 at 9:08 A.M., 11:03 A.M., 1:12 P.M., 2:13 P.M., and 3:39 P.M., showed the lid to one of the outdoor dumpster open. During an interview on 4/4/22 at 2:15 the Assistant Dietary Manager said he/she expected all facility staff to close the lid after dumping trash into the dumpster. Record review of the 2009 Food and Drug Administration (FDA) Food Code Chapter 5-501.110 entitled Storing Refuse, Recyclables, and Returnable's, showed: Refuse, recyclables, and returnable's shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents. Chapter 5-501.113 entitled Covering Receptacles,…

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 the audible (heard or capable of being heard) function of the call lights from the following areas: Resident room [ROOM NUMBER], the 400 Hall shower room and the 500 Hall shower room. This practice potentially affected 26 residents who resided on those halls. The facility census was 67 residents. 1. Observation and interview on 4/4/22 at 11:18 A.M., showed: - The call light string in the 500 Hall shower room was activated. - Certified Nurse's Assistants (CNAs) E and G were at the nurse's station. - CNAs E and G both said the call light from the 500 Hall shower room was not audible at the nurse's station. 2. Observation and interview on 4/4/22 at 11:24 A.M., showed: - The call light string in the 400 Hall shower room was activated. - Licensed Practical Nurse (LPN) B and the Maintenance Director were at the nurse's station. - LPN B and the Maintenance Director both said the call light was not audible at the nurse's station. 3. Observation 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 and interview, the facility failed to do the following: repair a 13 inch (in.) long by ¼ in. gap between a climate control unit and the wall where it was installed on resident room [ROOM NUMBER]; maintain the covebase (a type of trim that is installed along the base of an interior wall where the wall meets the floor which is used to protect the base of a wall from damage and to provide a finished look) area in good repair in resident room [ROOM NUMBER] and 301; failed to maintain the tiles in good repair, which exposed the metal studs underneath the layer of tile on the 300 Hall shower room; maintain the ceiling vent in resident room [ROOM NUMBER] in operable condition because the knob to open the vent was absent; maintain the paint on the ceiling of resident room [ROOM NUMBER] in good condition; maintain the ceiling of the kitchen in good repair; maintain the flooring of the dishwasher area in the kitchen in good repair; maintain the window mounted vent, which forced excess heat out 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.

Based on interview and record review, the facility failed to prevent a negative balance for one discharged resident (Resident #266) who was discharged on 3/26/21 and to address that negative balance until 4/5/22. This practice potentially affected 14 residents who allowed the facility manage their resident funds. The facility census was 67 residents. 1. Record review of the Trust Fund Yearly Detail Register showed: -Resident #266's family received $669.01, after the resident was discharged on 3/26/21, instead of $372.01, because $297.00 was spent on an insurance plan on 3/3/21 and not deducted from the resident's ledger. -Leaving a negative balance of $297.00 outstanding on the resident's account. During an interview on 4/5/22 at 11:13 A.M., the Business Office Manager (BOM) said the check that was written in March 2021 for $669.01 was written by a person without business office experience and that person forgot to subtract the $297.00 that was already spent on 3/3/21. .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to have advanced directives (documents that allow one to communicate their health care preferences when decision-making capacity is lost) and/or a Durable power of Attorney (DPOA- a person previously identified to make decisions for an individual in the event of inability to make wishes known) for one sampled resident (Resident #265) who had an Outside the Hospital Do Not Resuscitate (DNR - an order from a doctor that resuscitation should not be attempted if a person suffers cardiac or respiratory arrest) form signed by a family member; and to ensure physician's orders for a code status change were obtained when OHDNR forms were signed for two sampled residents (Resident #265 and Resident #7) out of 17 sampled residents. The facility census was 67 residents. Record review of the facility policy Advanced Directives policy revised 9/27/17 showed: -At the time of admission, each resident, DPOA or responsible party would be given written information regarding…

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 ensure an annual comprehensive assessment was completed for one sampled resident (Resident #47) and to complete a comprehensive admission assessment for one sampled resident (Resident #265) out of of 17 sampled residents. The facility census was 67 residents. Record review of the Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.1, October 2019 showed: -The Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff for care planning) is one of the three components of the RAI process. -The MDS is a core set of screening, clinical, and functional status elements, including common definitions and coding categories, which forms the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. -The items in the MDS standardize communication about resident problems and conditions within nursing homes, between nursing homes,…

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 resident and/or their representative with a summary of a baseline care plan that was developed within the first 48 hours of admission for one sampled resident (Residents #265) out of 17 sampled residents. The facility census was 67 residents. Record review of the facility's Baseline Care Planning policy revised 3/16/22 showed: -The baseline care plan would seek to develop a personal plan of care. -The baseline care plan should be completed within 48 hours. -The baseline care plan should be reviewed with the resident and a copy should be provided to the resident and the resident's designated representative. 1. Record review of Resident #265's admission nurses note dated 2/9/22 showed: -The resident was admitted to the facility via transport van. -The resident's physician was notified and physician's orders were obtained. Record review of the resident's baseline care plan dated 2/10/22 showed: -The resident was cognitively impaired, a high elopement risk and wandered. -The resident was independent with walking,…

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 the extent practicable, to include residents and their representatives in the care planning process and failed to conduct care plan conferences to include resident/resident representative participation for two sampled residents (Residents #26 and #57) out of 17 sampled residents. The facility census was 67 residents. Record review of the facility's Comprehensive Care Planning policy revised 11/1/17 showed: -The Interdisciplinary team and other staff needed as appropriate should meet to discuss resident care services and needs. -The resident and/or the resident's representative should participate as possible/appropriate. -The comprehensive care plan should strive to be person centered. 1. Record review of #26's Profile Face Sheet showed he/she: -Was admitted to the facility on [DATE]. -Had a diagnosis of multiple sclerosis (MS, a neurological disease that attacks the protective covering of the nerves, leading to impaired sensory and motor nerve…

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 arrangements were made to replace broken and scratched glasses for one sampled resident (Resident #41) out of 17 sampled residents. The facility census was 67 residents. 1. Record review of Resident #41's Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE]. Record review of the resident's Social Services notes dated November 2020 to December 2020 showed no Social Service notes mentioning the resident's vision needs. Record review of the facility's Tentative Optometrist List (a list of residents needing to see the optometrist), dated 11/30/21 showed: -The resident was on the list of residents scheduled to see the optometrist on 12/14/21. -Beside the resident's name under the heading Visit Reason was written Diluted Fundus Exam (DFE - a diagnostic exam for eye health) and beside that was hand written Needs new glasses. Record review of the resident's annual Minimum Data Set (MDS - a federally…

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 smoking assessments were completed on a quarterly bases to ensure one sampled resident (Resident #20) was able to smoke safely, out of 17 sampled residents. The facility census was 67 residents. Record review of the facility's undated Smoking Policy showed: -Smoking would be permitted by staff and residents in an approved outside location. -Residents must always be accompanied by a staff member to smoke and may not keep their own smoking materials. -Note: There was no mention of a resident assessment for ability to smoke safely or to determine what modifications may need to be considered to modify independent smoking so that resident safety was maintained. Record review of the facility's undated Smoking Assessment form showed: -Areas for resident's name, the date of the assessment, the resident's physician, and the resident's diagnosis. -Comprehensive Evaluation Results section with areas to mark for No problem identified 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 observation, interview and record review, the facility failed to assess placement of a percutaneous endoscopic gastrostomy tube (PEG tube - a tube that is placed into a patient's stomach as a means of feeding them when they are unable to eat) using the current standard of practice and to have a policy in place reflecting the standard of practice for one sampled resident (Resident #31) out of 17 sampled residents. The facility census was 67 residents. Record review of the facility policy titled Enteral Feedings revised 2/08 showed: -Placement of tube will be confirmed via aspiration. -If unable to confirm placement via aspiration, air instillation (auscultation) method may be used. -Placement will be confirmed prior to giving medications. -Note: The policy did not reflect the current standard of practice for assessing PEG tube placement. Record review of Center for Clinical Standards and Quality/ Survey & Certification Group (S & C) 12-47 dated 9/27/12 showed facility policies and procedures regarding…

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 necessary oversight and intervention; and failed to care plan, fully assess, and thoroughly document the behavioral needs of one sampled resident (Resident #29) who had a known behavior of targeting certain residents and pinching and scratching them. Additionally, the facility failed to fully assess the impact of the resident's behavior on other residents by not comprehensively assessing and documenting injuries (bruises and scratches) that were sustained from the pinching and scratching for one sampled resident (Resident #61) out of 17 sampled residents. The facility census was 67 residents. Record review of the facility's Behavior Record Guide, Informational dated 9/1/19 showed: -The monthly Behavior Record form (dated 9/1/19) should be completed to include the resident's name, diagnosis pertinent to the stated behavior (if known), any psychotropic medication pertinent to the stated behavior (if known), and target behavior.…

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.