Brookfield Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to update and revise problems and interventions on resident care plans to reflect current care needs for three residents,(Resident #4, #14 and #15), in a review of 16 sampled residents. The facility census was 25. Review of the facility policy, Comprehensive Care Plans, revised 10/31/24, showed the following: - It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the resident's comprehensive assessment; -The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff; -The comprehensive care plan will include measurable objectives and time frames…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow physician's orders for four residents (Resident #10, #16, #23, and #24) in a sample of 16 residents, and one additional resident (Resident #23). The facility census was 25. Review of the facility policy Transcription of Orders/Following Physician's Orders, last revised 05/18/24, showed the following: -The purpose of this policy is to ensure that all physicians' orders are followed; -To ensure a process is in place to monitor nurses in following physician's orders; -The Licensed Nurse will review electronic Medication Administration Records (MARs) & electronic Treatment Administration Records (TARs) on a routine basis to monitor for medications that were not administered to the resident due to unavailability, refusal, omission, etc. -If a medication is marked as not given, the reasoning for not being given should be explained in the progress notes and to the Director of Nursing (DON)/Assistant Director of Nursing (ADON)/Registered…

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 code status matched on all resident documents and their door name plates to ensure staff responded appropriately to provide or not provide Cardio Pulmonary Resuscitation (CPR) (an emergency procedure that combines chest compressions and rescue breathing to restart a person's breathing and heartbeat) according to the resident's wishes if the resident was found without a heart beat or respirations for four residents (Resident #20, #22, #24, and #229) in a sample of 16 residents. The facility census was 25. Review of the facility policy, Communication of Code status, last revised [DATE], showed the following: -It is the policy of this facility to adhere to residents' rights to formulate advance directives; -In accordance to these rights, this facility will implement procedures to communicate a resident's code status to those individuals who need to know this information; -The facility will follow facility policy regarding a resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide sufficient staffing to ensure one dependent resident (Resident #24) was able to smoke outside, ensure residents received restorative services or to ensure call lights were answered timely to accommodate resident needs for five residents (Resident #5, #13, #16, #22, and #24) in a review of 16 sampled residents. The facility census was 25. Review of the facility's policy, Call Lights Accessibility and Timely Response, revised 04/30/24, showed all staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desired, the appropriate personnel should be notified. During an interview on 06/12/25 at 7:30 P.M., the Assistant Director of Nursing (ADON) said the facility had no restorative program at this time. 1. Review of the undated Facility Assessment showed the following: -Average daily census is 23; -Disease/Conditions and physical/cognitive disabilities for…

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

Based on interview and record review, the facility failed to follow an antibiotic stewardship program as part of their infection prevention and control program that included antibiotic use protocols and a system to monitor antibiotic use for two residents (Resident #229 and #15), in a review of 16 sampled residents. The facility census was 25. Review of the facility policy, Antibiotic Stewardship Program, dated 06/29/23, showed the following: -To optimize antibiotic use in our nursing home and reduce unnecessary use of laboratory tests and antibiotics using a systematic approach; -This Facility Antibiotic Stewardship Program (ASP) will comply with all state and federal laws and regulations; -The ASP will be run by the Facility Antibiotic Steward, who will lead the Antibiotic Stewardship Team (AST); -At a minimum, the AST will be comprised of the Director of Nursing, a nurse with administrative duties, and a charge nurse; -The facility ASP will use a systematic evaluation of ongoing treatment which includes, but is not limited to; -Including a systemic evaluation of an ongoing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide pneumococcal vaccinations (a vaccine that can protect against pneumococcal disease) as indicated by the current Centers for Disease Control and Prevention (CDC) guidelines for four residents (Residents #15, #5, #229 and #4), of five residents reviewed for immunization status. Resident #15 developed symptoms of lethargy (a state of sleepiness or unresponsiveness) and decreased oxygen saturation (the measurement of oxygen circulating in the blood), resulting in a trip to the emergency room and a diagnosis of pneumonia, the resident was not up to date with pneumonia vaccines according to CDC guidelines. The facility census was 25. Review of the facility's policy Pneumococcal Immunizations, revised 05/14/2024, showed the following: -The purpose of this policy is to ensure that all residents residing in the facility are offered pneumococcal immunizations to prevent infection and the spread of communicable diseases. -As part of the admission process,…

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

Based on interview and record review, the facility failed to ensure staff training needs as identified in the facility assessment and the facility staff development plan were met. The facility also failed to ensure 12 hours of training were completed per calendar year to include dementia management and resident abuse prevention training per year for five certified nursing assistants (CNA)'s (CNA H, CNA F, CNA I, CNA J and CNA D), in a sample of five CNA's who have been employed over a year. The facility census was 25. Review of the facility's policy, Nursing Aide Training Program Policy, revised 05/18/24, showed the following: -This facility maintains an appropriate and effective nurse aide in-service training program for the purpose of ensuring the continuing competence of nurse aides; -The facility, with oversight from the Director of Nursing (DON), shall be responsible for the coordination and/or provision of nurse aide education; -Each nurse aide shall be provided at least 12 hours of in-service training annually, based on his/her employment date, not calendar year; -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 accurately code the Minimum Data Set (MDS), a federally mandated assessment completed by staff, according to the Resident Assessment Instrument (RAI) manual for two residents (Resident #24 and #27), in a review of 16 sampled residents and one closed record. The facility census was 25. Review of the Centers for Medicare and Medicaid Services (CMS), Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.18.11, Chapter 2, revised October 2023, showed the following: -Medicare and Medicaid participating LTC facilities are required to conduct comprehensive, accurate, standardized and reproducible assessments of each resident's functional capacity and health status; -Federal regulations require that (1) the assessment accurately reflects the resident's status (2) a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals; - In addition, an accurate assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and provide a copy of a complete baseline care plan, consistent with the resident's specific conditions, needs and risks that provide effective person-centered care that met professional standards of quality of care within 48 hours of admission to the facility for one resident (Resident #229), in a review of 16 sampled residents and one additional resident (Resident #23). The facility census was 25. Review of the facility policy, Baseline Care Plan, revised 05/18/24, showed the following: -The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care; -The baseline care plan will: -Be developed within 48 hours of a resident's admission; -Include the minimum healthcare information necessary to properly care for a resident, including, but not limited to: -Initial goals…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility staff failed to provide range of motion for limited mobility to one or more affected areas to increase range of motion (ROM), or prevent further decrease in range of motion for one resident, (Resident #13), in a review of 16 sampled residents. The resident said his/her contractures (permanent tightening of muscles, tendons, skin and other tissues, resulting in stiff and shortened joints that restrict normal movement) had gotten worse since he/she had been in the facility and now he/she had knots and pain in his/her arm and shoulder that are worse because of the contractures. He/She feared he/she will get more contractures and have more pain or skin issues. The facility census was 25. During an interview on 06/12/25 at 7:30 P.M., the Assistant Director of Nursing (ADON) said the facility did not have a restorative program at this time and did not have a policy related to restorative nursing or for maintaining ROM or preventing contractures. 1. Review 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 conduct a complete assessment to identify a history of trauma, the presence of symptoms related to the trauma, and triggers that may cause re-traumatization and to develop an individualized care plan with interventions to mitigate and eliminate these triggers for two residents (#13 and #23), in a review of 16 sampled residents. The facility census was 25. Review of the facility policy, Trauma Informed Care, revised 05/14/24, showed the following: -It is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally-competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization; -Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting…

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

Based on interview and record review, the facility failed to ensure one nurse aide (NA G), of one NA reviewed, completed a certified nurse aide (CNA) training program within four months of their employment in the facility. The facility census was 25. Per email communication on 06/17/25 at 11:54 A.M., the facility administrator said to his knowledge the facility did not have a policy addressing nurse aide certification within four months of employment. 1. Review of the facility provided list of employees hired since the last annual survey, showed NA G was hired on 12/12/24. 2. Review of NA G's employee file showed no documentation he/she completed a CNA training program within four months of his/her hire date. 3. Review of NA G's nurse aide registry check showed no documentation to show NA G had a CNA certification. 4. Review of the June 2025 nursing schedule showed NA G was scheduled as an evening shift CNA on 06/03/25, 06/04/25, 06/05/25, 06/07/25, 06/08/25 and 06/10/25. During an interview on 06/19/25 at 3:52 P.M., NA G said the following: -He/She had worked at the facility since…

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 drugs and biologicals were labeled in accordance with currently accepted professional principles when facility staff failed to date the label of multi-use vials of insulin (injectable medication to treat diabetes (inability to regulate blood sugar(glucose)) when first accessed and administered insulin from the opened, undated multi-use vial of insulin. Further review showed staff administered undated or expired insulin to one resident, (Resident #19), in a review of 16 sampled residents and one additional resident (Resident #23). The facility census was 25. Review of the facility policy, Administration Of Insulin Policy, revised 05/14/24, showed the following: -Insulin pens must be clearly labeled with the resident name, physician name, date dispensed, type of insulin, amount to be given, frequency and expiration date; -If the label is missing, the pen will not be used; a new pen must be ordered from the pharmacy; -Once opened, clearly labeled insulin pens may be stored at room temperature in a locked…

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 comply with state laws and designate a person as an administrator who was employed in the facility and served in that capacity on a full-time basis. This had the potential to affect all facility residents. The facility census was 30. 1. Observation on [DATE] at 9:00 A.M., outside the office labeled Administrator, showed the following: -The Assistant Administrator occupied the Administrator's office; -A State of Missouri Licensed Nursing Home Administrator License was displayed with the Administrator's name (the name on the license was not the assistant administrator's name, who was acting as the administrator); -The license was issued on [DATE] and expired on [DATE]. During an interview on [DATE] at 9:15 A.M. the Maintenance Director said the following: -The Assistant Administrator was an administrator in training; -The Administrator was not in the building very often; -The Administrator had been in the building two to three times since the beginning 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 store, prepare, and serve food in accordance with professional standards for food service safety. Staff failed to properly thaw potentially hazardous foods in order to prevent cross-contamination by not storing raw meat separately from fully cooked food items. Staff failed to store and handle food products to maintain quality and keep them free from potential contaminants by not properly sealing opened food items and not discarding dropped food items. Staff failed to ensure hygienic practices when preparing food for residents by not employing proper hand hygiene or thermometer probe sanitizing. Staff failed to ensure the kitchen ice machine's drain contained a sufficient air gap to prevent potential backflow into the machine. Staff also failed to ensure glass light bulbs were properly shielded in the food preparation area. The facility census was 31. Review of the facility policy, Food Storage (Dry, Refrigerated, and Frozen), dated 2016, showed the following: -Food shall be stored using appropriate methods to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a plan of care consistent with resident's specific conditions, needs, and risks to provide effective person-centered care for three residents (Residents #15, #23 and #28), in a review of 13 sampled residents, and one additional resident (Resident #3). The facility census was 31. Review of the facility policy, Care Plans, Comprehensive Person-Centered, dated December 2016, showed the following: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; -Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change; -The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met; c. When the resident…

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 provided grooming and hygiene needs for three residents (Residents #5, #6, and #12) and one additional resident (Resident #82), who were unable to perform their own activities of daily living (ADLs), in a review of 13 sampled residents. The facility census was 31. Review of the facility policy, Mouth Care - AM (morning), PM (afternoon/evening) and PRN (as needed), dated October 2010, showed the following: -The purpose of this procedure is to keep the resident's lips and oral tissues moist, to clean and freshen the resident's mouth, and to prevent infections of the mouth; -Review the resident's care plan to assess for any special needs of the resident. Review of the facility undated policy, Shaving the Resident, showed the following: -The purpose of this procedure is to promote cleanliness and to provide skin care; -Review the resident's care plan to assess for any special needs of the resident; (The facility 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide care in a manner that enhanced resident dignity and ensured full recognition of individuality when facility staff failed to provide personal care or pain medication when requested for two residents (Resident #20 and #28), in a review of 13 sampled residents. The facility census was 31. Review of the undated facility policy, Quality of Life-Dignity, showed the following: -Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality; -Residents shall be treated with dignity and respect at all times; -Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth; -Staff shall speak respectfully to residents at all times. 1. Review of Resident #20's face sheet showed the following: -He/She was admitted to the facility on [DATE]; -He/She was his/her own person. Review of the resident's facility medical diagnosis…

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 accurately assess the use of a lap buddy (a positioning device when the patient is unable to maintain upright position in the chair and is used to provide trunk and upper arm/body support for wheelchair mobility or self-feeding), as a restraint for one resident (Residents #12), in a review of 13 sampled residents, who was unable to easily and intentionally remove the lap buddy. The facility also failed to identify a medical symptom that supported the use of the restraint, and failed to develop a care plan for the lap buddy with interventions to minimize or eliminate the medical symptom and identify and address any underlying problems causing the medical symptom. The facility census was 31. Review of the facility's undated policy, Use of Restraints, showed the following: -Restraints shall only be used to treat the resident's medical symptoms(s) and never for discipline or staff convenience, or for the prevention of falls; -When the use of restraints is indicated, the least restrictive alternative will be used…

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 complete a significant change status assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment, required to be completed by facility staff, for two residents (Resident #5 and #15), in a review of 13 sampled residents. This assessment should have been completed within 14 days after the facility determined, or should have determined, there had been a significant change (major decline or improvement in the resident's status) in the resident's physical or mental condition which had an impact on more than one area of the resident's health status and required disciplinary review and/or revision of the care plan. The facility census was 31. Review of the Long Term Care Facility RAI User's Manual, version 3.0 showed the following: -A significant change is any decline or improvement in a resident's status that: 1) Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, is not self-limiting; 2) Impacts more than one area 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 have documentation of a Level I (level of care) PASARR (Pre-admission Screening and Resident Review), and then failed to file for a Level II PASARR (an in-depth assessment of the resident's mental health and intellectual needs) when conditions/diagnoses changed or were added for one resident (Resident #4) in a review of 13 sampled residents. The facility census was 31. Record review of the Missouri Department of Health and Senior Services (DHSS) guide titled, PASARR Desk Reference, dated 3/3/08, showed: -The PASARR is a federally mandated screening process for any person for whom placement in a Medicaid Title (XIX) certified bed is being sought. This is a Level I screening (completion of the DA124C form). -A Level II assessment is completed on those persons identified at Level I who are known or suspected to have a serious mental illness (such as schizophrenia, dementia, major depression, etc., mental retardation (MR) or related MR condition to…

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

Based on observation, interview, and record review, the facility failed to follow physician orders for one resident (Resident #3), who had an order for a decreased dose of medication, out of 13 sampled residents. Staff failed to follow policy to ensure the pharmacy label on the medication matched the physician's order resulting in staff administering the wrong dose of the medication. The facility census was 31. Review of the facility's undated policy, Administrating Medications, showed the individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Review of the facility undated policy for pharmacy notification, showed the following: -The facility notifies the pharmacy for any new orders for medications or treatments ordered by the physician; -The charge nurse was responsible to fax and/or call the pharmacy with the new orders. 1. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument…

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 appropriate treatment and services consistent with acceptable standards of practice to prevent urinary tract infections (UTIs) for two residents (Residents #5 and #82), who had a urinary catheter (a sterile tube inserted into the bladder to drain urine), in a review of 13 sampled residents. The facility reported three residents with a urinary catheter. The facility census was 31. Review of the facility's undated and untitled policy showed the following: -It is the policy of the facility to provide pericare to all residents who are unable to provide for themselves; -Peri-care with a catheter: Wash the catheter tubing from the opening of the urethra outward 4 inches or farther if needed. Do not pull on the catheter; -Peri-care with a suprapubic catheter (a sterile tube inserted through the abdominal wall into the bladder to drain urine): wipe around the suprapubic insertion site with wet wipe. Discard wipe and use a new wipe to wash…

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 prepare and serve bread and butter for any resident as directed in the approved menu. The facility census was 41. Review of the facility's undated policy on menus showed the menus are planned according to the basic four food groups and meet the standard requirements for nursing homes. Review of the menu for the noon meal on 01/28/20 showed staff was to serve crusted pork loin, roasted sweet potatoes, spinach bake, and bread and butter. All diets were to receive bread and butter. Observations on 01/28/20 between 12:03 P.M. and 12:46 P.M. showed staff served meal trays to all the residents. Staff did not serve bread and butter to any resident. During an interview on 01/28/20 at 1:01 P.M., [NAME] E said staff forgot the bread and butter. During an interview on 01/28/20 at 1:09 P.M., the dietary manager said she expected staff to serve bread and butter when it is on the menu. She expected staff to follow the menu and recipes. During interview on 01/28/20 at 3:06 P.M., the administrator said she expected staff to…

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

Based on observation and interview, the facility failed to ensure the ovens and range hood baffles were free of buildup and debris. The facility census was 41. Observation on 1/28/20 at 9:24 A.M. showed the following: -The bottom in each of the two ovens was heavily soiled with a buildup of debris; -The baffle filters within the range hood had a heavy buildup of grease and debris. Review of the facility cleaning schedule (no date) showed oven #1 (oven #2 was not on the cleaning schedule) and the range hood filters were to be cleaned on week 1 and week 3. There was no documentation these areas had been cleaned. During interview on 1/28/20 at 3:02 P.M., the dietary manager said she was not aware there was a buildup of debris in the ovens, and was not aware there was a buildup of grease and debris on the range hood baffles. She was not sure who was responsible for cleaning the range hood baffles. During interview on 1/28/20 at 3:06 P.M., the administrator said she expected the ovens and the range hood baffle filters to be clean and free of debris build-up.

Based on observation, interview, and record review, the facility failed to prepare food by methods that conserved nutritive value and flavor, and failed to serve food at a safe and appetizing temperature. The facility census was 41. Review of the facility's policy Food Temperatures, dated 01/16/08, showed correct serving temperatures for meats and vegetables/starches was 160 degrees Fahrenheit or greater. Review of the facility policy Nutrition Policies, dated 9/9/97, showed food is prepared to conserve nutritive value, flavor and appearance. 1. Review of the menu for the noon meal on 01/28/20 showed staff was to serve pork loin, sweet potatoes, and broccoli to residents on a pureed diet. (The facility identified four residents were to receive a pureed diet.) Review of the recipe for pureed pork loin showed to use chicken or beef base if the product needs thinning. Gradually add an appropriate amount of liquid (NOT WATER) to achieve a smooth, pudding or soft mashed potato consistency. Review of the recipe for pureed sweet potatoes showed to use (hot milk) if the product needs…

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 a safe and effective form of medication control for one resident (Resident #14), in a review of 17 sampled residents, and for one additional resident (Resident #100). Staff did not administer medications as ordered, did not compare pharmacy label with physician orders during medication preparation and administration, and did not observe a resident swallow his/her medication. The facility census was 41. Review of the facility's policy, Policy for Medication Administration and Maintenance, dated December 2018, showed the following: -No medication or treatment shall be given without an order from a person lawfully authorized to prescribe such and the order shall be followed; -No medications will be left unattended or unobserved by certified medication technician (CMT) or nurse administering to residents. Review of the Certified Medication Technician (CMT) student manual, dated April 2008, Lesson plan 13, Unit IV preparation 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 follow infection control practices while performing blood glucose monitoring (Accucheck) for two residents (Residents #24 and #91), in a review of 17 sampled residents. The facility census was 41. Review of the facility's policy, Infection Control Competency Validation - Finger stick/Blood Glucose Monitoring, dated November 2017, showed the following: -Wash hands. Put on gloves; -Clean and disinfect meter by wiping with PDI Sani-Cloth germicidal wipes. Let meter air dry thoroughly before testing; -Remove one test strip from vial and insert in meter; -Lay meter and supplies on clean field (ex. paper towel) at resident's bedside; -Select fingertip. Clean area with an alcohol wipe. Let area dry; -Lance fingertip. Touch edge of sample tip to blood drop and allow blood to be drawn into strip; -After the test is finished, the blood glucose result is displayed; -Discard the lancet in sharps container and test strip in biohazard bag; -Remove gloves. Wash hands or sanitize; -Put on clean gloves to clean/disinfect…

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.