Quail Run Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to allow one resident (Resident #1) to return to the facility without a documented reason in the medical record as to why the resident's needs could not be met. This affected one resident of three sampled residents. The facility's census was 32. Review of the facility provided policy titled, Transfer or Discharge Notice, dated March 2025 showed:-When a resident is sent to an acute care setting, this is considered a transfer, not a discharge, because the resident's return is generally expected; -If discharge is initiated by the facility after an emergency transfer to the hospital, the reason for discharge is based on the resident's status at the time the resident seeks return to the facility, not the reason for the initial transfer; -If the facility does not permit a resident's return to the facility, based on inability to meet the resident's needs, the facility will notify the resident, and/or his/her representative in writing, including notification 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 treat residents with dignity and respect, when staff failed to address one resident (Resident #33) by their preferred name of choice, failed to assist one resident with eating lunch (Resident #44) and when the facility staff failed to ensure one resident (Resident #41) was dressed in clean clothing. This affected three out 24 sampled residents. The facility census was 56. Review of the facility's undated Resident Rights Policy showed in part: -Residents have a right to a dignified existence and self-determination; -The facility shall protect and promote the rights of each resident; -The facility shall care for it's residents in a manner that promotes enhancement of each resident's quality of life. 1. Review of Resident #44's admission Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 8/18/24, showed: -Severe cognitive impairment; -Maximal assistance with showers and dressing; -Supervision 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 interviews the facility failed to maintain accommodation of needs when the facility staff did not ensure two of 14 sampled resident (Resident #46 and #39), had their call lights within reach while they were in their rooms. The facility census was 56. The facility did not provide a policy regarding call light use. 1. Review of Resident #46's Quarterly minimum data set (MDS, a federally mandated assessment completed by the facility staff) date 10/17/24 showed: - The resident had a Brief Interview for Mental Status (BIMS) score of 0, indicating sever cognitive impairment; - Diagnoses included: Dementia (a disease that affect the brain that causes memory loss and impairs reasoning), weakness and anxiety; - The resident used a walker for mobility; - The resident required the assistance of one staff for bed mobility, toileting, and showering. Review of the resident's undated comprehensive care plan does not address call light use. Observation on 11/4/24 at 9:34 A.M. showed: The resident was in…

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

Based on observations, interviews and record review, the facility failed to consider concerns and recommendations of the resident council members concerning issues of resident care and life in the facility and failed to communicate back with the resident council regarding their concerns as reported by ten of the 11 residents who participated in a group interview. This had the potential to affect all residents in the facility. The facility census was 56. Review of the facility's undated policy for grievances, showed, in part: - Residents have the right to voice grievances to facility or other agency that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal; - Such grievances include those with respect to care and treatment which is furnished as well as that which has not been furnished, behavior of staff and other residents; and other concerns regarding their Long Term Care facility stay; - Residents have the right to and the facility must make prompt efforts by facility to resolve grievances residents may have; - The facility must make…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure staff invoked (activated by verifying incapacity of the resident to make decisions) Durable Power of Attorney (DPOA) prior to allowing a resident to sign his/her Outside of Hospital Do Not Resuscitate (OHDNR) form which affected one of the 14 sampled residents, (Resident #30) and failed to obtain advance directives for code status (whether the resident wished to have cardiopulmonary resuscitation, CPR, if the resident's breathing stops or if the resident's heart stopped beating), which affected Resident #18. The facility census was 56. Review of the facility's policy for advance directives, revised [DATE], showed, in part: - Advance directives will be respected in accordance with state law and facility policy; - Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he/she chooses to do so; - If the resident 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure housekeeping and maintenance services was provided to maintain a sanitary, orderly and comfortable interior throughout the facility. The facility census was 56. Review of the facility's Floors policy, revised December 2009, showed in part: -All floors should be cleaned daily; -Floor cleaning procedures are maintained by the house keeping director. Review of the facility's undated house keeping daily cleaning duties showed: -Pull trash; -Dust/mop floors; -Clean toilet; -Dust horizontals; -Clean shower rooms; -Sitting and dining Rooms; -Resident rooms 100 - 119; -Resident rooms 120 - 139. The facilty provided no other policies on cleaning and environment. 1. Observation on 11/04/24 at 9:02 A.M., showed: -room [ROOM NUMBER] with dirt and debris on the floor; -The bathroom floor in room [ROOM NUMBER] was covered with dirt, and was sticky; -The toilet bowl in room [ROOM NUMBER] had brown debris on the sides and will not flush. 2. Observation 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 interviews and record review, the facility failed to ensure ten of eleven sampled residents who participated in a group meeting, knew who the Grievance Official was and how to file a grievance. The facility census was 56. Review of the facility's undated policy for grievances, showed, in part: - Residents have the right to voice grievances to facility or other agency that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal; - Such grievances include those with respect to care and treatment which is furnished as well as that which has not been furnished, behavior of staff and other residents; and other concerns regarding their Long Term Care facility stay; - Residents have the right to and the facility must make prompt efforts by facility to resolve grievances residents may have; - The facility must make information on how to file a grievance or complaint available to the residents; - The facility must establish a grievance policy to ensure prompt resolution of all grievances regarding residents' rights; - Upon request, provider…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews the facility staff failed to develop a comprehensive person-centered care plan for three of 14 sampled residents (Resident #25, #18, and #49). The facility census was 56. The facility did not provide a care plan policy. Review of the undated Resident Right's policy showed: - The resident had the right to participate in their person-centered care plan; - Participate in the development of goals and outcomes of care the care plan; - Request revisions to the person-centered care plan. 1. Review of Resident #25's Quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff), dated 10/2/24 showed: - The resident had a brief interview for mental status (BIMS) score of 12, indicating minimal cognitive deficit; - Diagnoses included: Obesity, urinary incontinence and diabetes type 2 (a disease in which the body does not process blood sugar properly); - The resident was bound to his/her wheelchair; - The resident was incontinent of bowel and bladder;…

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 staff failed to review and update care plans quarterly for two of 14 sampled residents (Resident #36 and #43).The facility census was 56. The facility did not provide a policy for care plan revisions and updates. Review of the undated Resident Right's policy showed: - The resident had the right to participate in their person-centered care plan; - Participate in the development of goals and outcomes of care the care plan; - Request revisions to the person-centered care plan. 1. Review of Resident #36's Quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff), dated 8/22/24 showed: - The resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating the resident had mild cogitative deficit; - Diagnoses included: Alzheimer's Disease (A disease of the brain that impairs memory and reasoning), urinary incontinence and constipation; - The resident required assistance from one staff to use 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 observations, interviews, and record review, the facility failed to ensure staff provided services that met professional standards of quality of care when staff failed to obtain an order for a resident to go to dialysis ( a procedure that removes waste products and excess fluid form the blood when the kidneys are no longer functioning properly) which affected one of the 14 sampled residents, (Resident #49). Additionally, the facility failed to monitor the settings of the low air loss mattress (an air mattress with tiny holes that helps prevent and treat pressure wounds and regulate skin temperature and moisture levels) which affected two residents, (Resident #21 and #30). The facility census was 56. Review of the facility's policy for medication orders, dated 2001, showed: - The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders; - A current list of orders must be maintained in the clinical record of each resident. 1. Review of Resident #49'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 observations, interviews, and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADL's) received the necessary services to maintain good personal hygiene when staff did not provide complete perineal care which affected three of the 24 sampled residents, (Resident #1, #21 and #25) and failed to ensure showers or bed baths were completed for Resident #21 and #43). The facility census was 56. Review of the undated policy for resident rights, showed, in part: - The facility shall care for its resident's in a manner and in an environment that promotes maintenance or enhancement of each resident's quality of life. The facility did not provide a policy for perineal care. 1. Review of Resident #21's Significant Change in Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/2/24 showed: - Cognitive skills moderately impaired; - Upper and lower extremities impaired on both sides; - Dependent…

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 ensure three of five sampled staff (Certified Nurse Aid (CNA) E, CNA D, CNA C) completed competencies upon hire and annually. The facility census was 56. The facility did not provide a policy for CNA competencies. 1. Review of the staff roster showed: - CNA E was hired 2/21/24; - CNA D was hired 8/21/23; - CNA C was hired 4/15/24. 2. During an interview on 11/7/24 at 1:58 P.M. the Administrator said: - She was unable to find CNA's E, D, C competencies from hire or annual; - Competencies were not being completed upon hire and annually; - She expected the CNA competencies to be completed upon hire and annually by the nurses.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to minimize adverse consequences related to medication therapy to the highest extent possible when the facility failed to ensure the consultant pharmacist reviewed each resident's medication for unnecessary medications, psychoactive medication, including gradual dosage reductions, and drug irregularities monthly and additionally failed to ensure the attending physician was notified of the pharmacist's recommendations. This affected three of the 24 sampled residents (Resident #1, #4 and #51). The facility census was 56. The facility did not provide the requested drug regimen review policy. 1. Review of Resident #4's medical record showed: -Initial admit date [DATE]; -admission date 9/3/24; - 8/14/24 a GDR (gradual dosage reduction) was attempted for Trazodone (used to treat insomnia) 50 milligrams (mg) and Zoloft (used to treat depression) 100 mg; -No other drug regimen reviews were found. Review of the resident's admission Minimum Date Sets…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure staff administered medications with an error rate of less than five percent (%). Staff made eight errors out of 30 opportunities for error, which resulted in an error rate of 26.67%. This affected three of the 14 sampled residents, (Resident #23, #35, and #48). The facility census was 56. The facility did not provide a policy for obtaining blood sugars, administration of insulin, administration of nasal sprays, or the administration of eye drops. Review of the website. mayoclinic.org. for obtaining blood sugars showed: - Wash and dry your hands and testing site thoroughly with soap and water before pricking your skin; - Don't use hand sanitizer before testing; - If using alcohol wipes, let the site completely dry prior to pricking the skin. 1. Review of Resident #48's physician order sheet (POS) dated [DATE] showed: - Order date [DATE] - Check blood sugars before meals and at bedtime related to diabetes mellitus; - Order date…

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

Based on observation, interview, and record review, the facility failed to ensure staff stored food in a sanitary manner and failed to maintain the kitchen in a sanitary manner. This had the potential to affect all residents residing in the facility. The facility census was 56. The facility did not provide a policy addressing food storage, kitchen cleaning and sanitation of the kitchen. Observation of the kitchen on 11/04/24 at 11:32 A.M.,showed: -The light switch by the coffee station was covered in dirt; -The vent above the hand washing sink was covered in dust and debris; -The back-splash behind the stove had food particles on it and was coming away from the wall; -The light in the dish-room is cracked; -Multiple cracked tiles on the dish room floor; -The inside of the dish room door is scuffed and scratched and the paint is peeling off of it; -Multiple tiles on the kitchen floor are broken; -There is a black substance on the wall behind the three compartment sink. Observation and interview on 11/06/24 at 10:45 A.M., showed: -Raw chicken quarters setting in water in the middle…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program to prevent flies in the facility, potentially effecting all residents. The facility census was 56. The facility did not provide the requested pest control policy. 1. Observation on 11/4/24 at 10:02 A.M. showed room [ROOM NUMBER] had six flies landing on the resident's property. 2. Observation: 11/4/24 at 10:11 A.M. showed room [ROOM NUMBER] had multiple flies in the room landing on the resident. 3. Observation on 11/4/24 at 12:30 P.M. showed: - Residents were at the dining tables with their heads on the table; - There was flies in the dining room; - The flies landed on residents and on their food; - Residents were swatting at the flies with their hands; - The residents ate the food that the flies landed on. 4. Observation on 11/6/24 at 5:51 P.M. showed: - Flies seen in the south dining room and crawling on the table's where residents were sitting; - Flies landed on residents hands and clothing;…

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 a safe and effective medication administration system that was free of significant medication errors when staff used insulin that was expired which affected one of the 14 sampled residents, (Resident #48). The facility census was 56. The facility did not provide a policy for administration of insulin. 1. Review of Resident #48's physician order sheet (POS) dated [DATE] showed: - Order date [DATE] - Insulin Lisper (fast acting insulin) per sliding scale. Blood sugar 151 - 200, give four units for diabetes mellitus for a blood sugar of 189. Review of the resident's medication administration record (MAR) dated [DATE] showed: - Insulin Lispro per sliding scale. Blood sugar 151 - 200, give four units for diabetes mellitus. Observation and interview on [DATE] at 12:08 P.M., showed: - Licensed Practical Nurse (LPN) B used the vial of Lispro insulin, opened [DATE] and discard after [DATE], and drew up four units in 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 ensure the Dietary Manager (DM) had the appropriate competencies and skills sets to carry out the functions of the food and nutrition service. The facility census was 40. The facility did not provide the requested job description for the dietary manger. Review of the DM's personnel file showed: -Date of hire 10/04/2023; -No certification for food service management or dietary manger was found. During an interview on 02/24/25 at 11:32 A.M., the DM said: -He has been DM for six months; -He has worked as a dietary aide but does not have any managerial experience; -The facility is getting ready to start on his dietary manager training; -He has not completed his/her dietary manager's course. During an interview on 02/27/25 at 03:10 P.M., the Administrator said: -She would expect the DM to know all regulations related to the kitchen -The DM has not completed the dietary training yet; -She would expect the DM to have the training completed. During an interview on 03/05/25 02:15 P.M., the Registered Dietitian (RD)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility staff failed to provide sanitary resident care when facility staff did not practice hand hygiene when perform person care tasks for one resident of 14 sampled residents (Resident #39). The facility census was 56. Review of the Handwashing/hand hygiene policy dated October 2023 showed: - All staff are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare- associated infections; - All staff are expected to adhere to hand hygiene policies; - Hand hygiene is indicated immediately before touching a resident, after contact with body fluids, after touching a resident, before moving from work on a soiled body site to a clean area of the body on the same resident, and immediately after removal of gloves; - Staff are supposed to wash hand when their hands are visibly soiled and after contact with residents with an infectious diarrhea including Clostridium Difficile (C. diff, a contagious bacteria 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, interviews, and record review, the facility failed to provide Skilled Nursing Facility (SNF) Advance Beneficiary Notices (ABN) (the form Centers for Medicare and Medicaid (CMS)-10055 to each resident. The SNF ABN provides information to residents/beneficiaries so they can decide if they wish to continue receiving the skilled services that may not be paid by Medicare and assume financial responsibilities. The facility utilized an outdated CMS-10123 Notice of Medicare Non-Coverage (NOMNC) form dated 12/31/2011, most current for is 9/2020. This affected three of three sampled residents (Residents #6, #16, and #32), facility census was 51. The facility did not provide a policy regarding ABN. 1. Review of Resident #6's medical records showed: -Notice of NOMNC CMS-10123 outdated form provided and signed on 4/17/23 -Used ABN form CMS-R-131 (exp. 6/30/23) dated 4/17/23 -No documentation of SNF ABN CMS-10055 form initially provided by facility -Facility provided surveyor an electronically signed CMS-10055 form dated 3/6/23 2. Review of Resident #16's medical records…

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, interviews, and record review, the facility failed to follow policy and revise care plans to accurately represent the care needs of five of 13 sampled residents (Resident #44, #18, #34, #9, and #43), including activity and recreation needs. The facility census was 51. Review of the facility Care Plans, Comprehensive Person-Centered policy, dated March 2022, showed: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident. 1. The interdisciplinary team, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The comprehensive, person-centered care plan is developed within seven days of the completion of required Minimum Data Set (MDS, a federally mandated assessment completed by staff) and no more than 21 days after admission. 3. 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 they provided care and treatments in accordance with professional standards of quality when staff failed to document when they administered physician ordered medications on the Medication Administration Record (MAR) for three of four sampled residents (Resident #4, Resident #29, and Resident #50) . The facility census was 51. Review of the facility's Administering Medications Policy, revised April 2019, showed: -Medications are administered in accordance with prescriber orders, including any required time frame; -If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose; -The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication before administering the next ones. 1. Review of Resident #4's annual Minimum Data Set (MDS), a federally mandated…

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 received the necessary services to maintain good grooming and personal hygiene when showers were not provided twice a week which affected four residents (Resident #9, #38, #43, and #39) of 13 sampled residents. The facility census was 51. Review of the facility's policy, Supporting Activities of Daily Living (ADL), dated 4/18, showed: -Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care) -If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time, or having another staff member speak with 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 observations, interviews and record review, the facility failed to provide ongoing program of activities designed to the the resident's needs for five residents (Resident #44, #18, #9, #39, and #43) of 13 sampled residents. The facility census was 51. The facility did not provide a policy in regards to activity programming. 1. Review of Resident #44's quarterly MDS, dated [DATE], showed: -He/she hears and sees adequately, makes self understood and usually understands others. - Score of 8 on the Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly residents). A score of 8 indicates moderaterly impaired cognitive skills. -He/she requires supervision with activities of daily living, such as personal hygiene, toileting and eating. He/she requires extensive assistance with dressing. -He/she is continent of bowel and bladder. -He/she has had one fall since admission. -He/she regularly receives antipsychotic medication. -He/she has the following…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to employ a qualified activity professional to oversee the activity program for the facility. The facility employes a full time activity director but he/she has not completed an approved activity profressional training program with the State of Missouri. The facility census was 51. The facility did not provide a policy regarding activity professional training and requirements. During an interview on 4/24/23 at 3:12 P.M., Resident #18 said: -He/she is blind. He/she says there are not activities and he/she is just existitng. -He/she attended church yesterday, first time he/she knew they had church. An interview was attempted with Resident #44 on 4/25/23 at 9:06 A.M. The resident would make eye contact but would not answer interview questions. During an interview on 4/27/23 at 10:27 A.M. the Activity Director said: -He/she start in the position in March 2022. He/she was perviously employed as a cook at the facility. -He/she is currently in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure nurse aides(NA) met the minimum qualifications which included satisfactory participation in a State-approved nurse aide training and competency evaluation program. This affected five staff members. The facility census was 51. The facility did not provide a policy regarding hiring and training nurses aides. Review of the facility employee list showed: -NA B was hired on 8/1/22. -NA C was hired on 11/4/22. -NA D was hired on 1/24/23. -NA E was hired on 1/25/23. -NA F was hired on 10/18/22. During an interview on 4/25/23 at 2:15 P.M., the Director of Nursing (DON) said: -He/she knows there are nurses aides employed by the facility that have not completed an NA training program. -NA B is currently enrolled in a NA training course. -NA C is currently enrolled in a NA training course. -NA D is not currently enrolled in a NA training course. -NA E is currently enrolled in a NA training course. -NA F was previously a licensed practical nurse and 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, interview and record review, the facility failed to ensure staff failed to maintain the kitchen in a sanitary manner. This has the potential to affect all residents residing in the facility. The facility census was 51. Review of the facility Kitchen Sanitation policy, dated 2016, showed: -Cleaning Rotation Daily: a. coffee machine b. storerooms c. drawers d. cleaning closet e. shelves f. ovens g. cupboards Weekly: a. refrigerators b. freezers c. ingredient bins d. ice machines e. food containers f. walls Annually: a. ceilings b. windows Observation of the kitchen on 4/24/23 at 11:04 A.M., showed: -Missing floor tiles near the three bin sink; -Dark material/food debris on the floor under the three bin sink, around the corners and legs of three bin sink and legs of stove. -Box fan on the floor, under the coffee machine, is dirty with dust; -Food debris and crumbs on shelves below the coffee maker; -The top of the inside of the microwave is dirty with food debris; -Door and bottom of oven have grease build up and food debris; -Food debris and crumbs on the plate…

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 develop and implement a comprehensive person-centered trauma informed plan of care which included measurable objectives and timeframes for one of 13 sampled residents (Resident #4). The facility census was 51. Review of the facility's Comprehensive, Person-Centered Care Plan Policy, revised March 2022, showed: - 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 implement for each resident; - Services provided for or arranged by the facility and outline in the comprehensive care plan are culturally competent and trauma-informed. Review of the facility's Trauma Informed and Culturally Competent Care policy, revised August 2022, showed: - To guide staff in providing care that is culturally competent and trauma informed in accordance with professional standards of practice; - To address the needs of trauma survivors by minimizing triggers and/or re-traumatization; - Staff are provided…

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 assess a resident for a history of trauma and provide trauma informed care to one of 13 sampled residents (Resident #4) with a diagnosis of Post Traumatic Stress Disorder (PTSD, a mental health condition that is triggered by a terrifying event). The facility census was 51. Review of the facility's Trauma Informed and Culturally Competent Care policy, revised August 2022, showed: - To guide staff in providing care that is culturally competent and trauma informed in accordance with professional standards of practice; - To address the needs of trauma survivors by minimizing triggers and/or re-traumatization; - Staff are provided inservice training about trauma and trauma informed care in the context of the healthcare setting; - Perform universal screening of residents, which includes a brief identification of exposure to traumatic events; - Develop individualized care plans that address past trauma in collaboration with the resident and family as appropriate; - Identify and decrease exposure to triggers that my…

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 provide food in a form designed to meet individual needs when they did nto ensure pureed foods were at an appropriate texture and consistency. The facility census was 51. Review of the facility's Pureed Food Preparation policy, dated 2016, showed: -Pureed foods will be prepared using standardized recipes to ensure quality, flavor, palatability, and maximum nutritive value. 1. Each menu cycle will be reviewed and ensure there is a pureed recipe on each item served. 2. Standardized recipes will be used to prepare all pureed foods. The recipes will be adjusted according to the number of pureed diets needed, indicating seasoning and technique to ensure the highest quality. 3. Recipes will not use water to thin pureed foods. Only broth, milk, juice, gravy, margarine or another appropriate condiment that preserves flavor shall be used. 4. Food thickener will be used only in accordance with a specific recipe or product instructions. Measure 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.