Ignite Medical Resort St Marys LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of Resident #74's After Visit Summary (discharge orders) from the resident's hospital stay, dated 7/19/24, showed an instruction to facility staff to attempt a voiding trial to remove the urinary catheter in one week (7/26/24) and, if unsuccessful, consult with a urologist. Review of the resident's Care Plan, dated 7/20/24, showed he/she had a urinary catheter in place. Review of the resident's admission MDS dated [DATE], showed: -Diagnoses of high blood pressure, renal failure (inability of the kidneys to adequately filter blood), benign prostatic hyperplasia (BPH, an enlarged prostate). -The resident had an indwelling urinary catheter. -The resident was not evaluated for urinary continence. -The resident was cognitively intact. -The resident required moderate assistance from staff for toileting. An admission progress note, dated 7/22/24, showed Nurse Practitioner (NP) A instructed facility staff to Continue Foley catheter, consider trial for DC. Review of the resident's medical record showed a lack…

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 oxygen equipment was stored using the proper infection control practices when not in use for one sampled resident (Resident #37) out of 18 sampled residents. The facility census was 84 residents. Review of the facility's policy titled Oxygen Handling and Transport dated January 2024 showed oxygen concentrators, cylinders, and equipment would be kept and maintained in such a way as to be compliant with all relevant health and safety guidelines. 1. Review of Resident #37's face sheet showed he/she admitted to the facility with the following diagnoses: -Chronic Obstructive Pulmonary Disease (COPD- a disease process that decreases the ability of the lungs to perform ventilation). -Unspecified Chronic (persisting for a long time) Bronchitis (inflammation of the lining of bronchial tubes, which carry air to and from the lungs. -Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity 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 one sampled resident (Resident #8) who had a diagnoses of Post-Traumatic Stress Disorder (PTSD- a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event) received trauma based interventions or developed a care plan that showed interventions for the staff to provide care to protect the resident and prevent trauma from recurring out of 18 sampled residents. The facility census was 84 residents. Review of the facility's policy titled Trauma Informed Care dated May 2024 showed: -The facility ensured that residents who were trauma survivors received culturally competent, trauma-informed care (a framework for relating to and helping people who have experienced negative consequences after exposure to dangerous experiences) in accordance with professional standards of practice and accounting for each resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. -The facility would assist 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 provide medically related social services for one sampled resident (Resident #62) who had major depressive disorder (a mental disorder characterized by a feeling of profound and persistent sadness or despair and was frequently accompanied by a loss of interest in things that were once pleasurable) out of 18 sampled residents. The facility census was 84 residents. A policy was requested related to social services and no policy was received. 1. Review of Resident #62's admission Record showed the resident was admitted to the facility on [DATE]. Review of the resident's Care Plan dated of 11/28/23 showed: -The resident had the potential for altercations in psychosocial well-being. -The staff needed to allow the resident time to answer questions, verbalize feelings, perceptions and fears. -Initiate referrals as needed for counseling and psychiatric services as needed. Review of the resident's quarterly 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 interview and record review, the facility failed to ensure the physician documented a rationale for why he/she disagreed with the pharmacist's recommendation in a timely manner for two sampled residents (Resident #25 and #62) out of 18 sampled residents. The facility census was 84 residents. Review of the facility's Pharmacy Services policy and procedure updated 5/2024, showed: -Medication Regimen Review-Reviews will be conducted in accordance with all state and federal requirements. Pharmacist medication reviews to the physician and nursing will be completed in a timely manner, but not later than five days from receiving. -The policy did not address the physician's response to recommendations. 1. Review of Resident #25's Face Sheet showed the resident was admitted on [DATE], with diagnoses including dementia (a chronic condition that causes a loss of cognitive functioning, such as thinking, remembering, and reasoning, to the point that it interferes with daily life), psychosis (a mental disorder that…

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 ensure the pureed (food that is blended, chopped, mashed, or strained until it becomes a soft and smooth consistency) sausage was made to a consistency without graininess. This practice potentially affected six residents who consume pureed diets. The facility census was 84 residents. 1. Observation on 8/22/24 at 7:50 A.M., during a taste test showed the texture of the pureed sausage, was grainy (having the existence of small particles). Observation on 8/22/24 at 7:51 A.M., showed Dietary [NAME] (DC) A tasted the pureed sausage and he/she noticed the sausage was grainy also. During an interview on 8/22/24 at 7:51 A.M., DC A said the pureed sausage needed to be smoother. During an interview on 8/22/24 at 7:57 A.M., the Dietary Manager (DM) said the sausage should have been processed in the food processor a little bit longer to be smoother after tasting it. During an interview on 8/22/24 at 10:11 A.M., DC A said he/she had not tasted the sausage after he/she pureed it earlier that morning and before placing the pureed sausage…

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 follow its Visitor's Food Policy, by storing foods in the visitor's food refrigerator which were labeled with names of residents the food was for and the dates the foods were received. This practice potentially affected between 3-5 residents. The facility census was 84 residents. Review of the Resident/Visitor food Policy dated 10/19, showed: -Policy -This facility supports and encourages residents to always maintain autonomy of living. The residents may have personal refrigerators to store food brought to the facility by or for the resident or the resident's family. -The facility requires that all food items be stored in a manner using proper sanitation, temperature, light, moisture ventilation and security. -Food and nutrition items brought to the facility by the residents, family members or other visitors will be evaluated by the nursing staff to ensure the items are appropriately and clearly labeled with the resident's name and the contents of packaging, and the date the item was delivered. -If the item is…

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 ensure the cover of the outdoor dumpster was in good repair to be close fitting and failed to prevent the accumulation of trash on the ground around the outdoor dumpster. The facility census was 84 residents. 1. Observation on 8/22/24 at 10:29 A.M., showed: -The dumpster lid with a 15 inch (in.) long crack. -A significant amount of debris and trash on the ground behind and at the side of the dumpster's. During an interview on 8/22/24 at 10:34 A.M., the Environmental Services (EVS) Director said: -He/she would have to notify the dumpster company for a new dumpster container. -He/she did not know there was a crack in the lid of the dumpster. -Sometimes when employees place trash in the dumpster. they may miss at times and the trash ended up on the ground around the dumpster.

Based on interview and record review, the facility failed to ensure resident signatures were obtained for goods and services for two sampled residents for funds (Resident #21 and #17); to disperse resident funds to the funeral home upon death for one sampled resident (Resident #268); and to submit resident money back to the State of Missouri timely for one sampled resident for funds (Resident #269). The facility census was 76 residents. A policy was requested and not received from the facility. 1. Record review of Resident #21's Resident Fund Statement dated 4/1/22 through 6/30/22 showed: -On 5/12/22 the resident received a haircut for $10.00. -On 6/24/22 the resident received a haircut for $10.00. Record review of the resident's Withdrawal Receipt dated 5/12/22 showed: -The resident received a haircut for $10.00. -The receipt was signed by the Business Office Manager (BOM) as facility representative payee and not signed by the resident. Record review of the resident's Withdrawal Record dated 6/23/22 showed: -$10.00 was requested to pay the Beauty Shop for the resident's haircut.…

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 to ensure resident trust funds were held in the resident trust fund account and/or failed to prevent commingling of resident money in the facility operating account for seven sampled residents (Resident #269, #267, #271, #272, #273, #274, #275) who were sampled for funds. The facility census was 76 residents. A policy was requested but not received from the facility. 1. Record review of Resident #269's financial information showed: -Personal Funds Account Balance Report (a report sent to the State of Missouri to show the amount of personal funds the resident had at time of death) showed the resident passed away on 9/4/21. The form was not submitted to the State of Missouri until 4/18/22. -The resident had $3789.77 which had been held in the facility operating account and not in the resident's trust fund account. Record review of the facility's Aging Report dated 10/21/22 showed: -The facility operating account including the last 12 months of transactions. -Resident #267 discharged on 1/2/21 and had a credit of $426.47 in the private…

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 check results of the Employee Disqualification List (EDL) as part of the employees' complete background check for two sampled newly hired employees (Employee A and Employee F) and to check their current employees against each quarterly EDL update to assure no employees were added to the EDL since their initial or previous EDL check. The facility had 151 employees. The facility census was 76 residents. Record review of the facility's Applicant Reference and Background Checks and Licensure and Certification Verification policy, undated, showed: -All selected applicants must have references checked, licensure and/or certification verified and have background check screenings before an employment offer can be made. -A conditional offer of employment will be made to an applicant pending a complete background check. -If any questionable information is returned the offer will not be confirmed. Record review of State Statute 192.2495.3 (2) showed: -Prior to allowing any person who has been hired as a full-time, part-time 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, interview, and record review, the facility failed to follow the physician's orders for enteral feeding (also known as tube feeding, is a way of delivering nutrition directly to your stomach or small intestine) for one sampled resident (Resident #56) out of 19 sampled residents. The facility census was 76 residents. Record review of the facility's Tube Feeding policy dated 11/19 showed: -Continuous tube feeding are based on a 22-hour consumption period or other time frame based on individual resident needs per Registered Dietician (RD) assessment and to be delivered over a 24 hour period. -There are no set hours for the tube feeding to be off. -An order was required by the physician or nurse practitioner for the type of formula and the rate. 1. Record review of Resident #56's admission Record showed he/she was admitted to the facility with an initial admission date of 9/17/15, and with a readmission on [DATE] with the following diagnosis: -Dysphagia (impairment in the production of speech…

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 residents were free from unnecessary anti-anxiety Pro Re Nata (PRN-as needed) medications (medications which affect psychic function, behavior, or experience) were limited to 14 days for one sampled resident (Resident #2) out of 17 sampled residents. The facility census was 76 residents. Record review of the facility's Psychotropic Medications (medications which affect psychic function, behavior, or experience) policy dated 12/2019 showed: -The resident's need for the medication needed to be monitored as well as when the resident had received the optimal benefits from the medication and when the medication can be lowered or discontinued. -The physician must certify the medication was necessary to treat a specific condition or behavior. 1. Record review of Resident #2's admission Record showed he/she was admitted to the facility on [DATE] and had the following diagnoses: -Anxiety Disorder (a psychiatric disorder causing feelings of…

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

Based on observation, interview and record review, the facility failed to ensure the lid of the dumpsters were closed for three days during the survey. The facility census was 76 residents. 1. Observations on 10/18/22, 10/19/22 and 10/21/22, at 8:15 A.M., 7:22 A.M. and 5:03 A.M. respectfully, showed: -The facility had two large trash containers/dumpers with two top lids attached on each dumpster. -The two trash dumpsters were enclosed by a fenced area with its sides measuring approximately eight feet tall with a large gate enclosing the dumpsters. -On 10/18/22, two lids on one of the containers were open lids. -On 10/19/22, one lid was open on each of the dumpsters. -On 10/21/22, one lid was open on one of the containers. During an interview on 10/21/22 at 7:06 A.M., the Dietary Manager said each person that uses the dumpster is responsible for closing the lids after they discard trash.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure a call light system or alternate system to contact staff for assistance was consistently accessible within the resident's reach for one resident (Resident #46) who was dependent on staff for several Activities of Daily Living (ADL - dressing, grooming, bathing, eating, and toileting) while he/she was in his/her room. The facility census was 76 residents. Record review of the facility's ADL policy, dated 11/2020 showed the facility will provide all residents with care, treatment and services according to the resident's individualized care plan. 1. Record review of Resident #46's Face Sheet showed he/she was admitted to the facility on [DATE] with diagnoses that included: -Parkinson's disease (a chronic nervous disease characterized by a fine slowly spreading tremor, muscle weakness, muscle stiffness, lack of coordination and a peculiar gait). -History of transient ischemic attack (TIA - temporary interference with blood supply to the brain). -Atrial…

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

Based on observation, record review and interviews, the facility failed to provide a clean environment when they did not keep resident bathrooms and the handrail on locked unit in clean condition. Lights on the locked unit were missing covers. The facility also failed provide a laundry service that was homelike. The facility census was 75. 1. Review of the facility's housekeeping checklist included: - Resident rooms to be completed daily; - The checklist included various rooms and the stairway on the locked unit but did not specify handrails in the hallway. Review of an undated work order which specified how to submit maintenance requests. Review of Resident Council Meeting Notes for November 2019 showed: - Residents indicated their rooms need thoroughly cleaned. Observations on 1/7/20 beginning at 10:51 A.M., showed the following bathroom floors contained dirt, dust, and debris: - Rooms #A106, #B108, and #B109. Observation on 1/9/20 at 5:22 P.M., showed the following in locked unit: - The hand rails on both sides of the hall, all the way down the hall were sticky to the touch; -…

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 staff provided a written notice of transfer or discharge to residents and their responsible person, including the reason for the transfer, in writing and in a language they understood. This effected three out of 19 sampled residents (Residents #4, #184 and #195). The facility census was 75. Review of the facility's policy for transfers or discharges, dated 11/20/19, showed: - When a resident is scheduled for transfer or discharge, the business office will notify nursing services of the transfer or discharge so that appropriate procedures can be implemented. - Nursing services is responsible for obtaining orders for discharge or transfer, as well as the recommended discharge services and equipment and providing the resident or representative with required documents (i.e., discharge summary and plan.) - The business office is responsible for informing the resident, or his/her representative of the facility's readmission appeal rights, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure three of 19 sampled residents (Resident #30, #49 and #52) dependent on staff assistance for activities of daily living (ADLs) received complete perineal care. The facility census was 75. 1. Review of the facility's procedure for Peri Care, dated December 2019, showed: - Wash the perineal area wiping front to back; - Separate the perineal fold and wash downward, front to back; - Continue to wash the perineum moving from inside outward to and including the thighs; - Do not reuse same disposable wipe to clean the inner perineal fold; - Wipe the rectal area thoroughly. 2. Review of Resident #30's care plan, start date 1/25/17, showed: - Resident will have daily care needs met; - Resident is dependent on staff for toilet use; - Resident requires frequent checks related to the resident's inability to recognize his/her own care needs. Review of the resident's Minimum Data Set (MDS), a federally mandated assessment instrument completed by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure staff followed infection control protocols to prevent the spread of infection related to hand hygiene during resident care when staff did not create a clean field during medication administration and when staff emptied a urinary catheter (a sterile tube inserted into the bladder to drain urine) drainage bag. This affected three out of 19 sampled residents (Residents #65, #194 and #195) and one additionally sampled resident (Resident #27). The facility census was 75. 1. Review of the facility's policy related to catheter care, dated December 2019, showed: - The purpose of this procedure is to prevent catheter-associated urinary tract infections. - Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag. - Empty the drainage bag regularly using a separate, clean collection container for each resident and prevent contact of the drainage spigot with the nonsterile container. - The policy 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 and interviews, the facility failed to treat residents with dignity and respect during meal times when they did not assist one of 19 sampled residents (Resident #54) who had difficulty getting food to his/her mouth. The facility censes was 75. Review of the facility's policy for Quality of Care - Dignity, dated December 2019, showed: - Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality; - Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. Review of the facility's policy for Assistance with Meals, dated November 2019, showed: - It is the facility's policy that residents shall receive assistance with meals in a manner that meets the individual needs of each resident. 1. Review of Resident #54's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/28/19, showed: - Impaired decision making ability; - Independent with eating; - Diagnoses of dementia and Parkinson'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 record review and interviews the facility failed to distribute interest to each resident evenly with an account in the Resident Trust Fund (RTF). This effected one sampled resident (Resident #66). The facility was holding funds for 17 residents at the time of the survey. The facility census was 75. Review of the facility policy titled Resident Trust Fund, dated April, 2018, showed the following: - Resident funds must be paid in an interest bearing account that is separate from the community's operating accounts. - Interest earned on the funds shall be credited to trust fund participant accounts on at least a quarterly basis. 1. Review of Resident #66's RTF account showed the following: - The beginning balance on 1/1/19 was $0.00; - The resident deposited $60.00 in his/her account on 5/13/19 making the balance $60.00; - The resident's balance was $60.00 in June with no deposits or withdraws, he/she did not have any interest added to his/her account; - The resident received $0.01 in interest for July, making his/her balance $60.01; - The resident received $0.01 in interest…

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

Based on observation, record review and interviews, the facility staff failed to ensure they provided care and treatment in accordance with professional standards of practice when staff failed to follow manufacturers' guidelines when administering medicated eye drops and nasal spray. Staff failed to follow physician orders for a wound treatment. This affected two of 19 sampled residents (Resident #65 and #27). The facility census was 75. 1. Review of the manufacturer's guideline for Flonase (used to treat seasonal allergies) showed the patient should: - Shake the medication well; - Gently blow nose before administration; - Occlude the opposite nare while administering medication. Review of Resident #65's current physician's order sheet (POS), dated January 2020, showed: - The physician ordered Flonase 50 mcg/actuation nasal spray (used to treat allergies). One spray in each nare every day; - Cleanse right inner foot wound with wound cleanser, pat dry. Skin prep peri (around outer edges of the wound bed) wound. Apply maxsorb (alginate, material used to absorb wound drainage) 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 closed record review, the facility failed to ensure staff completed a comprehensive discharge summary for two of 19 sampled residents (Resident #32 and #84) to include appropriate information about the residents' diagnoses, course of illness/treatment or therapy, a post-discharge plan of care to assist the resident to adjust to his/her new living environment when applicable. The facility census was 75. Review of the facility policy titled Transfer or Discharge, Preparing a Resident for, dated November, 2019, included the following: - Residents will be prepared in advance for discharge; - When a resident is scheduled for transfer or discharge, the business office will notify nursing services of the transfer or discharge so that appropriate procedures can be implemented; - A post-discharge plan is developed for each resident prior to his or her transfer or discharge. This plan will be reviewed with the resident, and/or his or her family, at least 24 hours before the resident's discharge 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, record review and interviews, the facility failed to date oxygen tubing and maintain oxygen concentrator filters clean and free of dust. This affected three of 19 sampled residents (Resident #75, #80, and #134). The facility census was 75. Review of the facility policy titled Respirator Care- Prevention of Infection, dated November 2018, showed the purpose of this policy is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and associates. It listed the Infection Prevention Related to Oxygen Administration as: - Change the oxygen cannula and tubing every seven days, or per state regulations (whichever is more strict) or as needed; - Wash filters from oxygen concentrators every seven days with soap and water. Rinse and squeeze dry. 1. Review of Resident #134's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff showed: - 12/13/19: Entry tracking record that showed 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.