Arbor View Nursing And Rehabilitation

Based on interview and record review, the facility failed to attempt a gradual dose reduction (GDR) for two residents (Residents #21 and #36) out of five sampled residents. The facility's census was 86. Review of the facility policy titled, Pharmacist Recommendations, dated 04/01/22, showed: - It will be the policy of this facility to provide pharmacist services to meet the needs of the residents through monthly regimen review (MRR) and properly addressing recommendations per federal and state guidelines; - The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. This review must include a review of the resident's medical chart. An electronic medication regimen review will be performed within 72 hours of admission for newly admitted residents, or as soon as reasonably possible; - The pharmacist must report any irregularities to the attending physician or Licensed Independent Practitioner (LIP) and the facility's Medical Director and Director of Nursing (DON), and these reports must be acted upon as soon as reasonably able, but prior to the…

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

Based on interview and observation, the facility failed to ensure bedtime snacks had been offered to all residents at bedtime. This had the potential to affect all residents in the facility. The facility census was 86. Review of the facility policy titled, Nutrition and Hydration Assistance, dated 04/01/22, showed: - Additional sources of nourishment should/may include provision of snacks; - Staff will make provision for appropriate snacks as requested or ordered by the physician. Review of the facility policy titled, Provide Diet to Meets Needs of Each Resident, dated 04/01/22, showed: - The facility would provide the services of a Registered Dietitian Nutritionalist or designee to participate in the interdisciplinary care planning team and assure that the nutritional needs of individuals living in the facility are met. Review of the meal times, as provided by the facility, showed breakfast was served at 7:30 A.M., lunch was served at 11:30 A.M., and dinner was served at 4:30 P.M. with a 16 hour gap between each dinner and breakfast. During group interview on 03/31/25 at 1:20 P.M.,…

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

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. The facility failed to ensure that foods were kept covered while waiting to be served and had policies and procedures in place for food brought in from outside the facility. These practices had the potential to affect all residents who are served food from the kitchen. The facility census was 86. Review of the facility policy titled,Food Delivery and Storage, dated 10/01/23, showed: - It will be the policy of this facility that foods shall be received and stored in a manner that complies with safe food handling practices; - Dietary/Food Services, or other designated staff, will maintain clean food storage areas at all times; - Dry foods that are stored in bins will be removed from original packaging, labeled and dated. Such foods will be rotated using a first in - first out system; - All foods stored in the refrigerator or freezer will be covered, labeled, and dated. 1. Observation 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 observation, interview, and record review, the facility failed to maintain or implement a policy regarding the acceptance, usage, and storage of foods brought into the facility for residents by food delivery services, family, and/or other visitors, to ensure the food's safe and sanitary handling, storage, and consumption. This deficient practice had the potential to affect all residents who ate food brought in by visitors. The facility census was 86. Review of the facility form titled, Resident Responsibilities and Rules, Appendix 4, undated, showed: - Food may be brought into our facility; - It must be kept in airtight containers; - Because of diet restrictions, nursing staff should be made aware of any food brought into the facility; - Should food need to be monitored, it will be kept in a designated room; - The policy did not address how facility staff will assist the resident in accessing and consuming the food brought in by visitors in a way that either separates or easily distinguishes from the facility food. Observation on 03/31/25 at 10:45 P.M., a refrigerator…

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 maintain essential equipment in a safe and operable working condition. This deficient practice had the potential to affect all residents. The facility census was 86. The facility did not provide a policy for equipment maintenance. Review of the following invoices showed: - On 12/16/24, an invoice for a laundry washer was serviced but no details of actions taken; - On 12/30/24, an invoice for a laundry washer was serviced with a valve and hose replaced. Observation on 04/02/25 at 9:40 A.M. of the laundry room, showed: - Three commercial laundry washing machines; - Two of the machines were covered in dust and debris and not in use; - The third machine was running a load of laundry. On top of the third machine was a plastic cup marked with a black line which indicated the fill line for bleach to pour into each load of laundry. During an interview on 04/02/25 at 9:40 A.M., Laundry Aide (LA) K said he/she had been a laundry employee for over a year and in that time, only one of the three washing machines had…

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 provide a safe and functional environment for the residents by allowing items to be stored on top of the overbed light fixtures for residents in three rooms. Storing items on the overbed light creates a hazard of the items falling on the resident below, and does not utilize the light fixtures as intended. The deficient practice had the potential to affect all residents and staff in the facility. The facility census was 86. The facility did not provide a policy regarding storing items on the overbed light fixtures. 1. Observation on 03/03/25 at 2:39 P.M., of Room B 5-1 showed a large picture in a wooden frame on the light above the resident's bed. 2. Observation on 03/31/25 at 11:09 P.M., of Room C 8-2 showed three medium sized stuffed animals, two medium glass figurines, and two small plastic animals on the light fixture above the bed on the left side of the room. 3. Observation on 04/01/25 at 1:00 P.M., of Room C 10-2 showed two large stuffed animals and three medium sized stuffed animals on the light fixture above the bed…

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 conduct at least twelve hours of nurse aide (NA) in-service education per year. This affected two Certified Nurse Assistants (CNAs) (CNA A and CNA B) out of two sampled CNAs. The facility's census was 86. The facility did not provide a policy regarding annual NA education. 1. Review of CNA A's employee file showed: - A hire date of 09/15/08; - A total of 2 hours 50 minutes of annual in-service training completed for the time frame of September 2023 through September 2024; - The facility failed to provide at least 12 hours of in-service education for September 2023 through September 2024. 2. Review of CNA B's employee file showed: - A hire date of 06/10/21; - A total of 5 hours 45 minutes of annual in-service training for June 2023 through June 2024; - The facility failed to provide at least 12 hours of in-service education for June 2023 through June 2024. During an interview on 04/02/25 at 3:05 P.M., the Administrator and Director of Nursing (DON) said they would expect CNAs to receive at least 12 hours of training…

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 consistent resident care for activities of daily living (ADLs) when the residents went an extended amount of time without showers for three residents (Resident #1, #2, and #3) out of 6 sampled residents. The facility's census was 92. The facility did not provide a policy regarding showers. 1. Review of Resident #1's medical record showed: - An admission date of 07/26/24; - Diagnoses of chronic obstructive pulmonary disease (COPD) with acute exacerbation (disease that makes breathing difficult), type 2 diabetes mellitus with hyperglycemia (trouble controlling blood sugar), need for assistance with personal care, conversion disorder with seizures or convulsions (a condition where psychological distress manifests as physical symptoms, including seizures), and Parkinson's disease without dyskinesia (Parkinson's without involuntary movements). Review of the resident's quarterly Minimum Data Set (MDS, a federally mandated 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.

Based on observation, interview, and record review, facility staff failed to properly maintain the temperature of hot food at or above 120 Degrees Fahrenheit (°F) for 12 residents (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, and #12), out of 12 sampled residents, at the time of meal service and failed to implement a system to monitor food temperatures at the time of service. Failure to maintain foods at the proper temperature has the potential to affect all residents receiving meal trays. The facility's census was 94. Review of the Missouri Food Code for the Food Establishments of the State of Missouri, provided by the facility and dated June 3, 2013, showed: - Refrigerated, potentially hazardous food shall be at a temperature of 41 degrees Fahrenheit or below when received; - Potentially hazardous food that is cooked to a temperature and for a time specified under section 3-4.11-3.401.13 and received hot shall be at a temperature of 135 degrees Fahrenheit. The facility did not provide a policy related to food service tray temperatures or a system of monitoring food tray…

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 one resident (Resident #1) out of eleven sampled residents when Resident #1 did not receive five doses of his/her seizure medication. The facility census was 87. Review of the facility's policy titled, Medication Administration, dated 09/01/22, showed: - Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards, in a manner to prevent contamination or infection; - Correct any discrepancies and report to the nurse manager; - The policy did not address what to do if the medication was not available. 1. Review of Resident #1's medical record showed: - admission date of 06/19/24; - Diagnoses of epilepsy (a neurological condition characterized by recurrent seizures due to abnormal electrical activity in the brain), history of malignant neoplasm of the brain (brain cancer), diabetes…

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 The facility failed to protect the rights of four of six sampled residents (Residents #1, #2, #3 and #4) by establishing a practice of revoking the resident's right to temporarily leave the facility by a physician's order for residents who are their own person, in response to that resident not following the rules established in the newly updated admission policy. The facility census was 86. Review of the facility's policy titled, Possession and/or use of Illegal Substances, Marijuana, and Alcohol, dated 2/1/2023 and updated 6/5/2024, showed: - If the facility staff identifies items or substances that pose risks to residents' health and safety and are in plain view, staff will confiscate them and alert their immediate supervisor; - The staff will notify resident's attending physician if resident is found with or suspected to be displaying signs/symptoms of being under the influence of illegal substance, alcohol, and/or marijuana to determine necessary interventions and/or medications/treatments they may need 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.

The facility failed to protect the rights of one of the six sampled residents (Resident #1) by prohibiting the visitation of a family member based on the facility's assumption that the family member was in possession of Marijuana. The census was 86. Record review of the policy on Possession and/or use of Illegal Substances, Marijuana, and Alcohol dated 2/1/2023 and updated 6/5/2024, showed: - If the facility staff identifies items or substances that pose risks to residents ' health and safety and are in plain view, they will confiscate them and alert their immediate supervisor; - The staff will notify resident ' s attending physician if resident if found with or suspected to be displaying signs/symptoms or being under the influence of illegal substance, alcohol, and /or marijuana to determine necessary interventions and/or medications/treatments they may need to hold; - The facility and/or physician also reserves the right to conduct alcohol and drug testing, suspend or discontinue out of facility pass (LOA); - In order to maintain and ensure the health and safety of 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.

Based on observation, interview, and record review, the facility failed to ensure safe smoking interventions for two residents (Resident #48 and #336) out of four sampled residents who smoke and four residents (Resident #24, #73, #76, and #80) outside the sample. The facility census was 83. Review of the facility's policy, Resident Smoking, revised 03/03/22, showed: - This facility provides a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and non-smoking residents; - Any resident who is deemed safe to smoke, with or without supervision, will be allowed to smoke in designated smoking areas (weather permitting), at designated times, and in accordance with his/her care plan; - Safe smoking measures will be documented on each resident's care plan and communicated to staff, visitors, and volunteers who will be responsible for supervising residents while smoking. Supervision will be provided as indicated on each resident's care plan; - Smoking materials of residents requiring supervision with…

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

Based on observation and interview, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These practices had the potential to affect all residents who are served food from the kitchen. The facility census was 83. Review of the facility's policy, Food Safety Requirement, dated 09/01/21, showed: - It is the policy of this facility to procure food from sources approved or considered satisfactory by the federal, state, and local authorities; - Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety. 1. Observation on 06/04/24 at 12:14 P.M., 06/05/24 at 12:14 P.M. and on 06/06/2024 at 10:45 P.M. of the walk-in refrigerator showed dirt and debris in the bottom of the refrigerator. 2. Observation on 06/04/24 at 12:14 P.M., 06/05/24 at 12:14 P.M. and on 06/06/2024 at 10:45 P.M. of the walk-in freezer showed: - Food items not labeled or dated, including bags of corn on the cob, meat, and cinnamon rolls; - Dirt and debris in the bottom…

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 documentation of on-going assessments, monitoring, and communication between the facility and the dialysis (a process for removing waste and excess water from the blood) center for one resident (Resident #14) out of one sampled resident. The facility's census was 83. Review of the facility's policy, Dialysis Care Guidelines, revised 03/15/24, showed: - Communication between the dialysis provider and center staff should included written communication that includes daily weights, changes in condition or mood, response to treatment, and evaluation of the vascular site; - Whether resident receives hemodialysis out of center or receives dialysis in house, communication is essential for continuity of care; - Be cognizant of medications ordered and timing of administration; - If resident is feeling ill or exhibiting unusual symptoms before the scheduled session, communicate symptoms to the out patient dialysis center and physician to ascertain if…

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 dumpsters were closed at all times and maintained to keep pests out and to keep the garbage contained in the dumpster. The facility census was 83. The facility did not provide a sanitation policy. Observations of the dumpster, located in front of the facility, showed: - On 06/06/24 at 8:05 A.M., the dumpster with the lid opened with visible bags and other miscellaneous items; - On 06/6/24 at 1:00 P.M., the dumpster with the lid opened with visible bags and other miscellaneous items; - On 06/6/24 at 4:10 P.M., the dumpster with the lid opened with visible bags and other miscellaneous items; - On 06/07/24 at 8:15 A.M., the dumpster with the lid opened. During an interview on 06/07/24 at 10:00 A.M., the Dietary Manager said she would expect staff to ensure the trash dumpster lids are closed after staff discard trash and other miscellaneous items. Housekeeping is also responsible for disposing of trash in the dumpsters. During an interview on 06/07/24 at 10:49 A.M., the Housekeeping and Laundry Manager said…

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 maintain infection control practices to prevent the development and transmission of infection for one resident (Resident #336) out of 18 sampled residents. The facility's census was 83. Review of the facility's policy, Infection Prevention and Control Program, revised 05/15/23, showed: - All reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment; - All staff shall demonstrate competence in relevant infection control practices; - Direct care staff shall demonstrate competence in resident care procedures established by our facility; - Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. Review of the facility's policy, Hand Hygiene, dated 09/01/21, showed: - Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice; - Hand hygiene 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 maintain an effective pest control program to control the fly population in the facility. This practice had the potential to affect all residents. The facility census was 83. Review of the facility's policy titled, Pest Control Program, revised 09/01/22, showed an effective pest control program is defined as measures to eradicate and control and contain common household pests (bed bugs, lice, roaches, ants, mosquitos, flies, mice, and rats). Review of the facility's Policy Explanation and Compliance Guidelines, dated 09/21/21 and revised on 09/01/22, showed: - Facility will maintain a written agreement with a qualified outside pest service to provide comprehensive pest control services on a regular and scheduled basis; - Facility will ensure that appropriate chemicals are used to control pests, but can be used safely inside the building without compromising resident health; - Facility will maintain a report system of issues that may arise in between scheduled visits with the outside pest service and treat as…

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

Based on interview and record review, the facility failed to make prompt efforts to resolve grievances for two of three sampled residents (Residents #1 and #2), and had the potential to effect all residents of the facility. The census was 96. Record review of the facility's policy titled Resident and Family Concerns/Complaints, dated 1/4/2022 showed: - The Concern/Complaint Officer is responsible for overseeing the concern/complaint process, receiving and tracking complaints and concerns through to their conclusion; - Concerns/Complaints may be verbal or written; - All staff involved shall make efforts to resolve quickly; - The investigation shall include: - The date and time of the alleged incident; - The circumstances surrounding the alleged incident; - The location of the alleged incident; - The names of any witnesses; - The resident's account of the alleged incident; - The employee's account of the alleged incident; - Recommedications for a corrective action. - The written decision will include at a minimum: - The date received; - The steps taken to investigate; - A summary 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 and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This potentially affected all residents. The facility census was 94. Record review of the facility's General Sanitation of the Kitchen policy, revised July 2019, showed: - Food and nutrition services staff will maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule; - Cleaning and sanitation tasks for the kitchen will be outlined in a written cleaning schedule; - Tasks will be assigned to be the responsibility of specific positions; - Frequency of cleaning for each task will be defined; - Employees will be trained on how to perform cleaning tasks; - On the cleaning schedule, employees will initial and date tasks when completed. 1. Observations of the kitchen on 11/29/22 at 11:20 A.M. and 12:11 P.M., showed: - A black griddle on top of the stove with a buildup of a hard black crusty substance; - Two black griddles on the bottom shelf by 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 provide a safe, clean and comfortable homelike environment. The facility census was 94. Record review of the facility's Preventative Maintenance Program policy, revised November 2017, showed: - A Preventative Maintenance Program shall be developed and implemented to ensure the provisions of a safe, functional, sanitary and comfortable environment for residents, staff and the public; - The Maintenance Director will be responsible for developing and maintaining a schedule for maintenance services to ensure that the buildings, grounds, and equipment will be maintained in a safe and operable manner; - The Maintenance Director shall assess all aspects of the physical plant to determine if preventative maintenance will be required; - If preventative maintenance will be required, the Maintenance Director shall decide what tasks need to be completed and how often to complete them; - The Maintenance Director shall develop a calendar to assist with keeping track of all tasks; - Documentation shall be completed for all…

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 send a copy of the notice for transfer or discharge to the resident and or the resident's representative, for six residents (Resident #15, #16, #17, #36, #66 and #70) out of seven sampled residents. The facility's census was 94. Record review of the Transfer and Discharge Policy, dated 9/22/22, showed: - Emergency Transfers/Discharges - initiated by the facility for medical reasons to an acute care setting such as a hospital, for the immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified); - Obtain physician's orders for emergency transfer or discharge, stating the reason the transfer or discharge shall be necessary on an emergency basis; - The original copies of the transfer form and the Advance Directive accompany the resident. Copies will be retained in the medical record; - Provide orientation for transfer or discharge to minimize anxiety and to ensure safe and orderly transfer or discharge, in a form 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 utilize proper technique during catheter (a tube inserted into the urinary bladder to drain the bladder) care for three residents (Resident #13, #41, and #66) out of three sampled residents, incontinent care for one resident (Resident # 25) out of two sampled residents, and wound care for one resident (Resident #13) out of a two sampled residents. The facility failed to maintain infection control practices for six residents (Resident #1, #9, #42, #44, #80, and #196 ) out of eight sampled residents during medication administration when facility staff did not wash or sanitize hands or touched medication with bare hands. The facility failed to ensure in the prevention of communicable disease in regards to Tuberculosis (TB) (a communicable disease that affects the lungs characterized by fever, cough and difficulty breathing) by not completing the admission TB screening and/or a yearly risk assessment for symptoms for five residents (Resident #16, #25, #26, #61, and #86) out of five sampled residents.…

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 handrails on the A, C, D and E Halls were properly maintained. This deficient practice had the potential to affect all residents on these halls. The facility census was 94. Record review of the facility's Preventative Maintenance Program policy, revised November 2017, showed: - A Preventative Maintenance Program shall be developed and implemented to ensure the provisions of a safe, functional, sanitary and comfortable environment for residents, staff and the public; - The Maintenance Director will be responsible for developing and maintaining a schedule for maintenance services to ensure that the buildings, grounds, and equipment will be maintained in a safe and operable manner; - The Maintenance Director shall assess all aspects of the physical plant to determine if preventative maintenance should be required; - If preventative maintenance should be required, the Maintenance Director shall decide what tasks need to be completed and how often to complete them; - The Maintenance Director shall…

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 residents with dignity and in a respectful manner by leaving one resident (Resident #25) out of 20 sampled residents exposed after staff left the resident's room. The census was 94. Record review of the facility's Resident Rights policy, dated 9/1/21, showed: - The resident with the right to be treated with respect and dignity; - Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits and meetings. 1. Observation of Resident #25 showed: - On 11/29/22 at 2:39 P.M., the resident lay in bed with the door open, in a shirt and brief, and uncovered; - On 11/20/22 at 3:45 P.M., the resident lay in bed with the door open, in a shirt and brief, and uncovered; - The resident visible from the hallway. Record review of the resident's medical record showed: - Diagnoses of Alzheimer's Disease (progressive mental deterioration), cognitive communication defect, and urinary incontinence; - Severe cognitive impairment. Record review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to obtain a physician's order for the code status (the type of emergent treatment a person would or wouldn't receive if their heart or breathing were to stop) for two residents (Resident #26 and #52) out of 20 sampled residents. The facility census was 94. Record review of the facility's Residents' Rights Regarding Advance Directives (a written statement of a person's wishes regarding medical treatment) policy, revised on [DATE], showed: - The facility will support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive; - On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive; - Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff; - Decisions…

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 written information to the resident and/or the resident's legal representative of their bed hold policy at the time of transfer to the hospital for two residents (Resident #36 and #66) out of seven sampled residents. The facility's census was 94. Record review of the facility's Bed Hold policy, revised April 2017, showed: - The bed hold policy will be reviewed with the resident, designated family member, and/or the resident's legal representative; - Before a resident will be transferred to a hospital or goes on therapeutic leave, a written Bed Hold policy will be given to the resident, designated family member, and/or the resident's legal representative; - In case of an emergency transfer, the resident, designated family member, and/or the resident's legal representative will be issued a copy of the Bed Hold policy within 24 hours by sending a copy with the resident's records at the time of the transfer. 1. Record review of Resident #36'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 document a complete and accurate Minimal Data Set (MDS), a federally mandated assessment to be completed by the facility, for three residents (Resident #16, #46, and #86) out of 20 sampled residents. The facility census was 94. Record review of the facility's Resident Assessment - Resident Assessment Instrument (RAI) policy, revised 8/18/2022, showed: - This facility makes a comprehensive assessment instrument of each resident's needs, strengths, goals, life history and preferences using the RAI specified by the Centers for Medicare and Medicaid Services (CMS). - The results of the assessment will be used to develop, review, and revise the resident's comprehensive care plan. 1. Observation of Resident #16 on 11/29/22 at 2:51 P.M. showed: - The resident sat in dining room with a Foley catheter (a tube inserted into the urinary bladder to drain the urine) collection bag that hung from the frame of his/her Broda chair (a wheelchair 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 interview and record review, the facility failed to develop and implement a baseline care plan consistent with the resident's specific conditions, needs, and risks within 48 hours of admission which included the minimum healthcare information necessary to provide care for one resident (Resident #52) out of five sampled residents. The facility's census was 94. Record review of the facility's Baseline Care Plan policy, dated 6/2/22, showed: - The facility will develop and implement a baseline care plan for each resident; - The care plan will be developed within 48 hours of admission; - It will include the minimum healthcare information necessary to properly care for a resident including, but not limited to the initial goals based on admission orders, medical provider orders, dietary orders, therapy services, and social services; - The admitting nurse, or supervising nurse on duty, shall gather information from the admission physical assessment and other information; - Once needs, goals and interventions were established, it will be documented in a designated format; - A…

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 implement a care plan with specific interventions tailored to meet individual needs for two residents (Resident #9 and #55) out of 20 sampled residents. The facility census was 94. Record review of the facility's Care Plan policy, dated 6/2/22, showed: - The facility will develop and implement a comprehensive person centered care plan for each resident; - The care plan will be consistent with the resident rights, professional standards of practice, medical provider orders and resident's goals and preferences; - It will include measurable objectives and timeframes to meet a resident's special medical, nursing, mental and psychosocial needs that will be identified in the resident's comprehensive assessment. 1. Record review of Resident #9's medical record showed: - An admission date 8/5/22; - Diagnoses of congestive heart failure (CHF) (a condition in which the heart doesn't pump blood as well as it should), chronic obstructive pulmonary disease (COPD) (a group of lung diseases that block airflow and make it…

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 obtain physician orders for five residents (Resident #9, #16, #17, #26 and #53) out of 20 sampled residents. The facility census was 94. Record review of the facility's Oxygen Administration policy, dated 5/4/22, showed oxygen to be administered under orders of a medical provider, except in cases of emergency. 1. Record review of Resident #9's medical record showed: - admission date 8/5/22; - Diagnoses of congestive heart failure (CHF) (a condition in which the heart doesn't pump blood as well as it should) and chronic obstructive pulmonary disease (COPD) (a group of lung diseases that block airflow and make it difficult to breathe). Record review of the resident's Physician Order Sheet (POS), dated 11/30/22, showed no physician's order for oxygen. Observations of the resident showed: - On 11/29/22 at 3:03 P.M., the resident sat in a wheel chair in his/her room with oxygen in use at 3.5 liters per minute (3.5 L/min) by nasal cannula; - 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, and record review, the facility failed to provide consistent resident care for activities of daily living (ADL's) when the residents went an extended amount of time without showers for four residents (Resident #28, #55, #66, and #71) out of 20 sampled residents, and one resident (Resident #1) outside the sample. The facility census was 94. Record review of the facility's Resident Showers policy, revised 5/4/22, showed: - The facility will assist residents with bathing to maintain proper hygiene and help prevent skin issues; - The policy did not address how often showers to be given. Record review of the facility's Bed Baths policy, revised 11/10/22, showed: - Document the procedure. 1. Record review of Resident #1's medical record showed: - An admission date of 9/16/16; - Diagnoses of morbid obesity, major depressive disorder (MDD) (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily…

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 treatment and care of standard of practice by not following the bowel regimen policy for one resident (Resident #55) out of 20 residents. The facility census was 94. Record review of the facility's Bowel Regimen policy, revised 4/5/2022, showed: - Will monitor the residents bowel movements (BM) and provide clinical best practice interventions as needed for a resident to have regular bowel movements; - Resident BM's will be evaluated and documented daily; - If a resident does not have a BM for 72 hours, the clinical team shall be alerted; - If the resident has any as needed (PRN) orders for bowel elimination assistance, it should be followed; - If the resident has no PRN order, notify the physician to obtain an order; - Monitor the resident's response to administration of bowel elimination assistance; - If no results, notify the physician; - Evaluate potential causes of constipation and implement interventions as needed to reduce causes. 1. Record review of Resident #55's medical record showed: - An admission date 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 reposition two residents (Resident #13 and #26) out of two sampled residents who were identified as at risk for pressure ulcers (damage to the skin and/or underlying tissue as a result of pressure). The facility also failed to follow physician ordered wound care orders for one resident (Resident #13) out of two sampled residents. The facility census was 94. Record review of the facility's Pressure Injury (damage to the skin and/or underlying tissue as a result of pressure) Prevention and Management policy, revised on 3/3/22, showed: - The purpose will be to prevent avoidable pressure injuries and the promotion of healing existing pressure injuries; - Intervention will be based on specific factors identified in the risk assessment, skin assessment and any pressure injury assessment; - Evidence-based interventions for prevention will be implemented for all residents assessed at risk or who have a pressure injury present. Basic or routine care…

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 staff failed to ensure residents with limited range of motion (ROM) received appropriate treatment and services to increase their ROM and/or prevent a further decrease in their range of motion. The facility staff failed to perform restorative services as recommended by the occupational therapist (OT) for one resident (Resident #36) out of 5 sampled residents. The facility census was 94. Record review of the facility's Restorative Nursing Program (RNP) policy, revised, 5/4/2022, showed: - The facility will provide maintenance and restorative services to maintain or improve a resident's abilities to the highest practicable level; - Cognitive and physical functioning of all residents will be assessed in accordance with the facility's assessment protocols; - The interdisciplinary team, with the support of the physician, will assure the ongoing review, evaluation, and decision making regarding the services needed to maintain or improve resident's abilities in accordance with the resident's comprehensive assessment, 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.

Based on observation, interview and record review, the facility failed to provide proper incontinent care for two residents (Resident #25 and #26) out of two sampled residents. The facility census was 94. Record review of the facility's Perineal Care policy, revised on 5/4/22, showed: - If the perineum should be grossly soiled, turn the resident on his/her side, remove any fecal material with toilet paper, then remove and discard. Cleanse the buttocks and anus, front to back, vagina to anus in females, scrotum to anus in males, using a separate washcloth or wipes. Thoroughly dry; - Reposition the resident in a supine (lying face up) position. Change gloves if soiled and continue with perineal care; - Remove gloves and discard, perform hand hygiene. 1. Record review of Resident #25's medical record showed: - An admission date of 9/26/15; - Diagnoses of Alzheimer's Disease (progressive mental deterioration), cognitive communication defect, and urinary incontinence; - Severely cognitively impaired; - Totally dependent on staff for toileting. Observation of Resident #25 on 11/30/22 at…

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

Based on interview and record review, the facility failed to follow physician's orders and the facility policy on getting weights on new admissions to monitor the nutritional status for two residents (Resident #54 and #55) out of three sampled residents. The facility census was 94. Record review of the facility's Weight Monitoring policy, revised, 6/2/2022, showed: - Weight can be a useful indicator of nutritional status; - Significant unintended changes in weight may indicate a nutritional problem; - A weight monitoring schedule will be developed upon admission for all residents; - Weights should be recorded at the time obtained; - Newly admitted residents should have weights monitored weekly for four weeks; - If clinically indicated, weights should be monitored daily; - All other residents' weights should be monitored monthly. 1. Record review of Resident #54's medical record showed: - An admission date of 11/5/22; - Diagnoses of dysphagia (difficulty swallowing foods or liquids), aphasia (trouble speaking or understanding other people when speaking), and memory deficit; - A…

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 documentation of ongoing assessments, monitoring, and communication between the facility and the dialysis (a process for removing waste and excess water from the blood) center for two residents (Resident #17 and #66) out of two sampled residents. The facility census was 94. Record review of the facility's Hemodialysis (dialysis) policy, revised March 3, 2022, showed: - The facility will assure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice, including an ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility; - The licensed nurse will communicate with the dialysis facility via telephonic or written format, such as a dialysis communication form or other form, that will include but not limit itself to, medication administration (initiated, held or discontinued),…

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 post the nurse staffing data with all the required components in a clear and readable format. The facility's census was 94. Record review of the facility's Nurse Staffing Posting Information policy, dated 6/2/22, showed: - The daily staffing sheet will be posted on a daily basis and will contain the facility name, the current date, the current resident census, the total number and the actual hours worked by the licensed and unlicensed staff directly responsible for resident care per shift; - The facility will post daily and at the beginning of each shift. Observations of the nurse staffing information posted on the wall across from the nurse's station showed; - On 11/29/22 at 2:03 P.M., the posted nurse staffing information, dated 11/23/22, with no information for 11/29/22; - On 12/1/22 at 11:26 A.M., the posted nurse staffing information, dated 11/30/22, with no information for 12/1/22; - On 12/2/22 at 12:58 P.M., the posted nurse staffing information, dated 11/30/22, with no information for 12/2/22. During…

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 medications in a safe and effective manner. The facility census was 94. Record review of the facility's Medication Administration policy, revised 4/7/22, showed: - Identify the expiration date; - If medication expired, notify the nurse manager; - Staff to observe the resident consumption of medications. 1. Observation on 12/2/22 at 8:50 A.M., of a medication pass showed: - Licensed Practical Nurse (LPN) G provided Resident #44 with an inhaler while the resident sat in the the therapy room; - While the resident self-administered his/her inhaler, LPN G left the therapy room and closed the therapy room door, went to the medication cart further down the hallway, obtained a blood pressure cuff, and returned to the therapy room; - LPN G gave the resident his/her oral medication in a pill cup to hold; - LPN G left the therapy room and closed the therapy room door, went to the medication cart further down the hallway, obtained water for the resident to take his/her medications, and returned; - LPN G failed 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 document accurate immunization status, provide information and education to each resident or the resident's representative of the influenza vaccine (a vaccine used to protect against influenza), pneumococcal vaccines (a vaccine used to protect against pneumonia bacteria) for two residents (Residents #16 and #26) out of five sampled residents. The facility's census was 94. Record review of the facility's Patient Immunization policy, revised February 2022, showed: - Influenza recommend annually for all residents; - Pneumococcal recommended for resident 65 years and older. Record review of the facility's Immunization Recommendations for Residents of Long-Term Care Facilities Immunization Manual, undated, showed: - Influenza recommended annually for all residents; - Pneumococcal PCV 13 (Pneumococcal conjugate vaccine that protects against 13 types of pneumococcal bacteria) and PPSV23 in persons 65 and older years, unless contraindicated, will be…

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.