Lewis County Nursing Home District

Based on observation, interview and record review, the facility failed to ensure staff followed professional standards of practice when staff failed to follow treatment orders for one resident, (Resident #2), in a review of 13 sampled residents. The facility census was 45. Review of the facility policy, Dressings, Dry/Clean, revised September 2013, showed the following:-Verify that there is a physician's order for this procedure;-Review the resident's care plan, current orders, and diagnoses to determine if there are special resident needs;-Check the treatment record. 1. Review of Resident #2's Face Sheet showed the resident had diagnoses of spina bifida (a congenital condition in which part of the spinal cord and its meninges (three membranes layers that cover and protect your brain and spinal cord) are exposed through a gap in the backbone, often causing paralysis of the lower limbs), diabetes, reduced mobility, obesity and muscle weakness. Review of the resident's five-day Prospective Payment System (PPS) 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 the necessary treatment and services consistent with standards of practice, when the facility failed to ensure staff cleaned one resident's (Resident #2's) pressure ulcer (an injury to skin and underlying tissue resulting from prolonged pressure on the skin, most often on bony areas of the body) according to physician's orders, failed to complete weekly skin assessments to include measurements, appearance, and any other wound characteristics, and failed to notify the physician of a change in the wound as directed by the facility policy. Facility staff also failed to turn and reposition one resident (Resident #4), who had a pressure ulcer. The facility census was 45. Review of the facility policy, Dressings, Dry/Clean, revised September 2013, showed the following:1. Verify that there is a physician's order for this procedure;2. Review the resident's care plan, current orders and diagnoses to determine if there are special 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.

Based on interview and record review, the facility failed to ensure staff demonstrated the appropriate skills to effectively respond to one resident (Resident #17), who had a diagnosis of dementia, in a review of 13 sampled residents, when the resident became aggressive toward the staff. The facility failed to identify and implement approaches to address the resident's behaviors including agitation and striking out. When the resident was not redirectable, Nurse Assistant (NA) J restrained the resident by holding the resident's wrist to the resident's chest and wrapped his/her arms around the resident and sat him/her on the floor. The facility census was 45.1. Review of Resident #17's face sheet showed the resident had diagnoses of mild cognitive impairment and dementia. Review of the resident's Care Plan, dated 04/17/25, showed the resident had dementia and at times had delirium but was usually pleasantly confused. The resident was alert and oriented to his/her name only. He/She was usually able to make his/her needs and wants known. From time to time, he/she perceived a situation…

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 the Quality Assurance (QA) committee meetings included the required members, including the Medical Director. The facility census was 45. During an interview on 09/25/25 at 5:40 P.M., the Administrator said the facility did not have a policy for Medical Director Responsibilities. Review of the facility Medical Director Agreement, dated 07/03/23, showed the following:-Medical Director Responsibilities included serving on facility committees, including QA and assist Administrator in implementing committee recommendations and plans of action;-Medical Director Services included QA committee;-Signed by the Medical Director on 07/17/23. Review of the undated, Policy and Procedure for the QA Committee, showed the following:-Monthly, on the third Wednesday of each month, a QA Meeting will be held at a designated location;-The Medical Director, all attending physicians, Nurse Practitioners and the Director of Nursing, Assistant Director of Nursing, Medical Records Director, Dietary Manager and Administrator will regularly…

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.

Refer to event id DCUR12 Based on observation, interview and record review, the facility failed to ensure staff treated one resident (Resident #35) in a review of nine sampled residents, with dignity and respect when Certified Nurse Assistant (CNA) C performed a Covid (Coronavirus-infectious disease) test on the resident without talking with the resident prior to administering the test to request permission, to educate to the rationale or preparation for testing, or to ensure privacy of the resident when tested. The census was 52.

Refer to event id DCUR12 Based on interview and record review, the facility failed to ensure one resident (Resident #1), in a review of nine sampled residents, remained free from misappropriation of property when the resident's iPad (an electronic tablet/computer) came up missing and was presumed stolen. The facility census was 52.

Refer to event id DCUR12 Based on observation, interview and record review, the facility failed to follow professional standards of practice when Certified Nurse Assistant (CNA) C performed a Covid (Coronavirus-infectious disease) test (an invasive procedure where a cotton swab is inserted in a resident's nasal passages and a sample collected for testing) on one resident, (Resident #35), in a review of nine sampled residents. Resident #35 had not been assessed by a licensed nurse to determine the resident had symptoms that necessitated testing. Instead, CNA C performed the test without any professional basis for testing and without documented training to show he/she received appropriate training to perform the test. The facility census was 52.

Refer to event id DCUR12 Based on observation, interview and record review, the facility failed to provide incontinent care for one additional resident, (Resident #29), of nine sampled residents. The census was 52.

Refer to event id DCUR12 Based on observation, interview and record review, the facility failed to ensure one newly hired nurse assistant (NA) (NA B), of one NA employee file reviewed, obtained their certification within the required four month time frame. The census was 52.

Refer to event id DCUR12 This deficiency is uncorrected. For previous examples, refer to Statement of Deficiencies dated 11/17/23. Based on observation, interview and record review, the facility failed to ensure staff utilized appropriate personal protective equipment (PPE) during nasal swab testing (cotton swab up both nostrils) for one resident, (Resident #35), in a review of one resident tested for COVID-19 (an infectious disease caused by severe acute respiratory syndrome). The census was 52.

Based on interview and record review, the facility failed to implement their Quality Assurance and Performance Improvement (QAPI) program. This had the potential to affect 52 of 52 residents who resided at the facility. Findings include: During an interview on 11/17/23 at 11:06 AM, the Administrator and Infection Preventionist (IP), who was the facility's QAPI Lead, stated the facility did not have a QAPI Council. The Administrator stated that the facility's QA (Quality Assurance) committee were the same people involved in the QAPI program. The IP was asked if minutes were kept of the QAPI meetings. The IP stated, I haven't sat down and had a formal meeting in quite some time. The IP stated it was difficult to get staff together for a QAPI meeting. The IP stated she gathered information from the fall committee, the weekly antibiotic report, and fall worksheets and reviewed that information to identify any concerns. The IP stated that information was reviewed during meetings and taken back to the floor staff. The IP was asked how she developed benchmarks for measuring improvement 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 interview and record review, the facility failed to establish and maintain an infection prevention and control program (IPCP) for recording incidents of infections identified under the facility's IPCP, surveillance, tracking and trending, and the corrective actions taken by the facility. The facility failed to update their infection control policies on an annual basis. The facility also failed to provide assistance with eating in a manner to potentially prevent cross-contamination for two of 24 sampled residents (Resident (R) 19 and R24) observed during dining. The census was 52. Findings include: 1. Review of a document titled, Centers for Disease Control (CDC) National Healthcare Safety Network (NHSN) Long Term Care Facility Component Tracking Infections in Long-Term Care Facilities dated January 2020, indicated, surveillance is defined as the ongoing systematic collection, analysis, interpretation, and dissemination of data. A facility infection prevention and control (IPC) program should use surveillance to identify infections and monitor performance of practices 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 interview and record review, the facility failed to maintain an infection prevention and control program (IPCP) that included a functional antibiotic stewardship program. The failure to have a system in place that monitored antibiotic use in accordance with established protocols has the potential to affect all 52 residents of the facility. In addition, the facility failed to ensure one Resident (R41) had appropriate clinical indications for the use of an antibiotic. The census was 52. Findings include: 1. Review of a CDC document undated titled, The Core Elements of Antibiotic Stewardship for Nursing Homes indicated improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority. Antibiotic stewardship refers to a set of commitments and actions designed to 'optimize the treatment of infections while reducing the adverse events associated with antibiotic use'. All nursing homes should take steps to improve antibiotic prescribing…

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) assessment for three (Resident (R) 51, R6 and R16) of 24 sampled residents reviewed for quality-of-care issues. Failure to code the MDS correctly could potentially lead to inaccurate federal reimbursements and inaccurate assessment and care planning of the resident. The census was 52. Findings include: 1. Review of R51's electronic medical records (EMR) titled Resident Face Sheet located under the Resident tab indicated the resident was admitted to the facility on [DATE]. Review of R51's EMR titled nursing Progress Notes, located under the Resident tab indicated the resident sustained a fall on 11/02/23. Review of a document provided by the facility titled admission MDS with an Assessment Reference Date (ARD) of 11/06/23 failed to identify R51 sustained a fall. During an interview on 11/16/23 at 12:34 PM, the MDS Coordinator (MDSC) confirmed the error for R51 and missed the fall the resident sustained on…

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 revise their pneumococcal vaccine policy to reflect current pneumococcal vaccination guidelines. This failure increased the risk for residents to not be vaccinated per current guidelines and contract pneumonia. The census was 52. Findings include: Review of the CDC recommendations, revised on 02/09/23, indicated the CDC recommends pneumococcal vaccination for all adults 65 years or older If PCV20 is used, a dose of PPSV23 is NOT indicated. For adults 65 years or older who have only received PPSV23 [Pneumococcal polysaccharide vaccine], CDC recommends giving 1 dose of PCV15 or PCV20. The PCV15 or PCV20 dose should be administered at least 1 year after the most recent PPSV23 vaccination. Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. For adults 65 years or older who have only received PCV13, the CDC recommends you either give 1 dose of PCV20 at least 1 year after PCV13, or give 1 dose of PPSV23 at least 1 year after PCV13. Review of a policy 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, interview and record review, the facility failed to ensure staff treated one resident (Resident #35) in a review of nine sampled residents, with dignity and respect when Certified Nurse Assistant (CNA) C performed a Covid (Coronavirus-infectious disease) test on the resident without talking with the resident prior to administering the test to request permission, to educate to the rationale or preparation for testing, or to ensure privacy of the resident when tested. The census was 52. The facility did not provide a policy regarding dignity when requested. Review of the booklet, Resident Rights For Long-Term Care in Missouri, showed residents should be treated with consideration and respect and with full recognition of dignity and individuality. 1. Review of Resident #35's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by the facility, dated 10/6/23, showed the following: -Adequate hearing; -Clear speech; -Sometimes understands others; -Severely impaired cognition; -Short and long term memory problem; -No rejection of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one resident (Resident #1), in a review of nine sampled residents, remained free from misappropriation of property when the resident's iPad (an electronic tablet/computer) came up missing and was presumed stolen. The facility census was 52. On 1/5/23, the administrator was notified of the past noncompliance which occurred on 12/25/23. On 12/26/23 the administrator identified Certified Nurse Aide (CNA) D as misappropriating Resident #1's ipad (electronic tablet/computer) after review of facility camera footage. Upon discovery, CNA D was suspended, the facility conducted an investigation and notified appropriate parties, including local law enforcement. Inservicing of staff was conducted where the abuse and neglect policy, which included misappropriation of resident property, was reviewed and the facility reported they planned to replace the resident's ipad. The deficiency was corrected on 1/5/24. Review of the undated facility policy, Prevention…

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, record review and policy review, the facility failed to ensure an alleged injury of unknown origin was reported to the State Survey Agency (SSA) in a timely manner for one of three (Residents (R) 19) residents reviewed for reporting allegations to the SSA in a timely manner. The census was 52. Findings include: Review of the admission Record in the electronic medical record (EMR) under the Profile tab revealed R19 was admitted to the facility on [DATE] with a diagnosis of dementia with behavioral disturbances. During an observation on 11/14/23 at 3:06 PM, R19 was in the activity room and had bruising on his/her neck. Review of the Progress Notes dated 11/16/23 revealed R19 had two small bluish reddish bruises to the right side of his/her neck. The note indicated the nurse talked to R19's family member and both agreed that R19 slept in unusual positions either in bed or in the recliner and he/she could have bruised him/herself. The resident was unable to say how the bruising on…

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, record review, the facility failed to complete a significant change assessment for one of 24 sampled residents (Resident (R) 21) after R21 suffered a cerebral vascular accident (CVA) which resulted in R21 needing a feeding tube due to being unable to take food or fluids by mouth. The census was 52. Findings include: Review of R21's Face Sheet, located in the electronic medical record (EMR) under the Resident tab, revealed R21 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, atrial fibrillation, and essential hypertension. Review of R21's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/02/23 and located under the RAI tab of the EMR, revealed R21 did not have a feeding tube. Review of R21's Dietary Quarterly Note dated 05/12/23 at 7:13 PM and located under the Resident tab of the EMR, revealed the resident was on a regular/mech [mechanical] soft diet. The resident eats in the east activity area and is assisted…

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 professional standards of practice when Certified Nurse Assistant (CNA) C performed a Covid (Coronavirus-infectious disease) test (an invasive procedure where a cotton swab is inserted in a resident's nasal passages and a sample collected for testing) on one resident, (Resident #35), in a review of nine sampled residents. Resident #35 had not been assessed by a licensed nurse to determine the resident had symptoms that necessitated testing. Instead, CNA C performed the test without any professional basis for testing and without documented training to show he/she received appropriate training to perform the test. The facility census was 52. During interview on 1/11/24 at 3:21 P.M., the Director of Nursing (DON) said the facility did not have a policy for Covid testing. Review of the undated facility job description for CNA's showed the following: -Immediate Supervisor: charge nurse; -General responsibilities to the facility: 1. Follow company policies and procedures; 2. Greet all visitors, staff and most…

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 provide incontinent care for one additional resident, (Resident #29), of nine sampled residents. The census was 52. Review of the facility policy, Perineal Care, last revised 2/2018 showed the purpose of this procedure was to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. 1. Review of Resident #29's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/2/23, showed the following: -Diagnoses included Alzheimer's disease (progressive disease that destroys memory and other important mental functions); -Occasionally incontinent of bladder and bowel; -Required partial to moderate assist for toileting and personal hygiene. Review of the resident's care plan, dated 12/13/23, showed the following: -Incontinent of bladder and bowel at times; -Resident will be clean and free of odors; -Resident required staff assist to go to the restroom. Provide pericare with incontinent…

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 pressure ulcer prevention measures were completed per facility policy and consistent with professional standards of practice, for one resident out of a sample of two residents (Resident (R) 16) reviewed for pressure ulcers. The facility failed to conduct thorough weekly skin assessments, which included measurements, descriptions, and stage of a right heel wound to be able to identify a decline or an improvement, or new skin conditions. These failures had the potential to delay identification and treatment of any new wounds the resident might develop. The census was 52. Findings include: Review of R16's EMR located under the Resident tab indicated the resident was admitted to the facility on [DATE] with a diagnosis of unspecified dementia. Review of a document provided by the facility titled Braden Scale for Prediction of Pressure Sore Risk dated 09/02/22, indicated R16 scored 15 and was identified to be at risk for the development of pressure…

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, observation, staff interviews, and facility policy review, the facility failed to assess nutritional status after a significant weight gain/weight loss, and failed to take corrective action after the facility determined the weight gain and loss was an error for two (Resident (R) 6 and R43) of four residents reviewed for nutrition in a total sample of 24 residents. Findings include: 1. Review of R6's electronic medical record (EMR) titled Resident Face Sheet located under the Resident tab indicated the resident was admitted to the facility on [DATE] with diagnoses that included unspecified dementia and anorexia. Review of R6's EMR titled Vitals located under the Resident tab revealed the resident had a significant weight gain from 09/02/22 to 10/03/22 of 45.5 pounds. There was no evidence in the clinical record that a re-weigh was obtained nor was there evidence the resident's weight was taken during the month of 11/22. On 12/07/22 the resident weight was 178.5 and then lost 41.7 pounds 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 one newly hired nurse assistant (NA) (NA B), of one NA employee file reviewed, obtained their certification within the required four month time frame. The census was 52. Review of the undated facility policy, Lewis County Nursing Home Job Description-Nursing, showed: -Position: Certified Nurse Assistant (CNA); -Qualifications: Must be [AGE] years old. Must be certified (non-certified personnel will be offered classes at the facility and must become certified within the specified guidelines); -General Responsibilities to the facility: Follow company policies and procedures. Adhere to professional standards, follow policy and procedures and abide by federal, state and local requirements. Review of a undated document provided by the facility, titled Job Description Report by Department, showed NA B's original hire date and current hire date were both 6/13/23. He/She was employed full time as a CNAT (Certified Nurse Assistant 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 interview, record review, and facility policy review, the facility failed to ensure pharmacy recommendations were acted upon/responded to in a timely manner for monthly medication regimen reviews for one of five sampled residents (Resident (R) 43) reviewed for unnecessary medications. The census was 52. Findings include: Review of R43's Consultant Pharmacist Communication to Physician, dated 06/28/23 and provided by the Director of Nursing (DON), revealed, New regulations in effect November 28, 2017, require all PRN [as needed] psychotropic medications (including Ativan) to be limited 14 days. Therefore, in order for the facility to remain compliant, the PRN order for Ativan needs to be discontinued. Please review and consider DISCONTINUING the PRN order for Ativan. Hand-written on the communication was re-eval [re-evaluate] q [every] 7 days. The communication contained no physician response to the recommendation. Review of R43's Consultant Pharmacist Communication to Physician, dated 09/26/23 and provided by the DON, revealed, In order for the facility to remain compliant,…

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, staff interviews, and facility policy review, the facility failed to ensure two residents (Resident (R) 51 and R43) of five residents reviewed for unnecessary medication were being monitored for behaviors while taking psychotropic medications, additionally, failed to identify an indication for the use of a psychotropic medication, and failed to attempt Gradual Dose Reductions (GDRs) or document a rationale for the reason not to attempt a GDR. Findings include: 1. Review of a document provided by the facility titled Assisted Living Physician Orders dated 08/26/23, indicated R51 was prescribed Haldol 1 milligram (mg) to be administered by mouth at bedtime for agitation. Review of R51's electronic medical record (EMR) titled Resident Face Sheet located under the Resident tab indicated the resident was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. Review of R51's EMR titled Physician Orders dated 10/31/23, indicated the resident was to be administered Haldol 1 mg…

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 a written notice of transfer to the resident and/or resident representative when five residents (Resident #13, #47, #50, #52 and #54), in a review of 17 sampled residents, were transferred to the hospital or another facility. The facility census was 56. Review of the undated facility policy, Transfer or Discharge Notice, showed the following: -A resident and/or his/her representative (sponsor) will be given a 30-day written notice of an impending transfer or discharge from our facility; -Under the following circumstances, the notice will be given as soon as it is practicable but before the transfer or discharge: a. The transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility; b. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; c. The safety of the individuals in the facility 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 interview and record review, the facility failed to inform residents and resident representatives of their bed hold policy at the time of transfer to the hospital for five residents (Resident #13, #47, #50, #52 and #54), in a review of 17 sampled residents, who were transferred to the hospital or another facility. The facility census was 56. 1. Review of the undated facility policy Transfer or Discharge Notice showed the following: -A resident, and/or his or her representative (sponsor), will be given a 30-day written notice of an impending transfer or discharge from our facility. -Under the following circumstances, the notice will be given as soon as it is practicable but before the transfer or discharge: a. The transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility; b. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; c. The safety 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 provide an ongoing program of meaningful activities on a daily basis to meet the interests and the physical, mental, and psychosocial well-being for four residents (Residents #8, #32, #33, and #47), in a review of 17 sampled residents, and for six additional residents (Residents #1, #9, #10, #14, #25 and #46). Staff failed to ensure weekend and evening activities were provided for residents. The facility census was 56. Review of the undated facility policy Activities showed the following: CONDUCTING ACTIVITIES: It is the policy of this facility that the activity director/coordinator be responsible for overseeing activity programs; Procedure: 1. The activity coordinator is responsible for overseeing all activity programs; 2. Resident seating arrangements are planned through the activity coordinator so that residents can achieve their maximum viewing and hearing potential; 3. The activity coordinator shall welcome all visitors and help them…

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 consistently implement, evaluate, and modify interventions, in accordance with current standards of practice, as necessary to reduce the risk of falls for three residents (Resident #23, #52, and #54) in a review of 17 sampled residents. Resident #52 fell multiple times from 3/24/21-4/17/21 and ultimately sustained a dislocated shoulder ( an injury that occurs when the top of upper arm bone pops out of the socket in the shoulder blade) and fractured finger. The facility staff failed to use proper technique during gait belt (canvas belt placed around the resident's waist to assist with ambulation and transfers), transfers for two residents (Resident #4 and #31), when the resident did not bear weight, or bore only minimal weight, during transfers. The facility census was 56. Review of the undated facility policy Falls and Fall Risk, Managing showed the following: Falls and Fall Risk, Managing: Based on previous evaluations and current data,…

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 offer residents a daily bedtime snack for one resident (Resident #8), in a review of 17 sampled residents, and for four additional residents (Residents #9, #10, #14, and #25), who participated in group interview and reported bedtime snacks were not offered on a routine basis at the facility. The facility census was 56. Review of the undated facility policy, Serving Snacks (Between Meal and Bedtime), showed the following: Purpose: The purpose of this procedure is to provide the resident with adequate nutrition. Preparation: 1. Review the resident's care plan and provide for any special needs of the resident; 2. Assemble equipment and supplies needed; 3. Check the tray before serving the snack to be sure that it is the correct diet ordered and that the food consistency is appropriate to the resident's ability to chew and swallow; 4. Ensure that the necessary non-food items (i.e., flexible straw, special devices, etc.) are on the tray. Report or replace…

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.