Westview Nursing Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide protective oversight for one resident (Resident #4), in a review of eight sampled residents. Resident #4, who resided on the facility's locked unit, had a history of elopement. Resident #4 obtained the fenced courtyard door access code and left the facility without staff knowledge, unaccompanied and without prior authorization. He/She returned 20 minutes later, using the same door code access to regain entry into the facility courtyard, without staff knowledge. The resident used the front door access code to leave through the locked unit courtyard door; the door codes were the same and had not been changed to two different codes every week per the facility's procedure. The resident said he/she had planned to hitch-hike, but the weather was too cold, so he/she returned to the facility. The facility census was 59. Review of the facility policy, Elopements and Wandering Residents, revised 06/12/24, showed the following: -The facility ensures 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of individual needs for one resident (Resident #1), in a review of sampled four residents. The facility failed to address the resident's communication barrier, provide effective communication tools, and ensure all staff were aware of the communication tools necessary to determine the resident's needs. The facility census was 60. Review of the facility's policy for communication with persons with limited English proficiency (LEP), last reviewed on 6/30/23, showed the following: -Purpose of the policy was to ensure that all residents receive care in a language that they understand; -Facility would take reasonable steps to ensure that persons with LEP had meaningful access and an equal opportunity to receive skilled nursing care and participate in activities and programs; -The policy of the facility was to ensure meaningful communication with LEP residents involving their medical conditions and treatment;…

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 resident (Residents #1), in a review of four sampled residents, was free from unnecessary psychotropic medications. The facility administered a medication ordered for itching to the resident following an incident of agitation which staff identified was a response to the resident's communication barrier. The facility failed to ensure an appropriate indication for use of a newly ordered antipsychotic medication implemented following an incident where the resident responded with physical aggression after another resident pushed him/her onto the bed. The facility census was 60. Review of the facility's Psychotropic and Antipsychotic PRN (as needed)) Medication Orders Guideline, dated 11/28/17, showed the following: -While there may be isolated situations where pharmacological intervention was required first, these situations do not negate the obligation of the facility to develop and implement non-pharmacological interventions;…

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 maintain a sanitary environment in the kitchen, failed to ensure food items in storage and in the refrigerators/freezers were properly labeled, dated, and sealed to protect from potential contamination, and failed to ensure an air gap between the ice machine and the floor drain. The facility census was 53. Review of the facility's policy, Receiving and Storing Food and Supplies, dated as last reviewed 6/30/23, showed the following: -Dry food storage: Storage area shall be easily accessible for receiving new items. The walls, ceiling, and floor shall be maintained in good repair and regularly cleaned. Any opened products shall be placed in seamless plastic or glass containers with tight-fitting lids or Ziploc bags. Open products may also be sealed utilizing plastic film or tape. -Frozen foods: Foods to be frozen shall be stored in airtight containers or wrapped in heavy-duty aluminum foil, plastic film, or special laminated papers, date and label a received date. -Food storage: All products shall be dated upon receipt or when…

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 quarterly Quality Assessment and Assurance (QAA) committee meetings. The facility census was 53. Review of the facility's QAPI Plan Policy, last reviewed 07/09/21, showed the following: -This QAPI plan provided guidance for the facility overall quality improvement program. Quality assurance performance improvement principles will drive the decision making within the facility. Decisions would be made to promote excellence in quality of care, quality of life, resident choice, person directed care, and resident transitions; -QAPI activities are integrated across all parts of the facility. Each department would have a representative on the QAPI committee. If a representative is not available, the department area will still be addressed through committee discussions. The QAPI activities would cross departments and staff across all departments wouldl work together to assure the facility addresses all concerns and strives to continuously improve the provided services. The facility strives to employ evidence based…

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

Based on record review and interview, the facility failed to keep residents from going into a negative balance which allowed the residents to spend another resident's money without written authorization for 32 residents (Resident #4, #5, #11, #12, #15, #17, #18, #19, #20, #22, #23, #25, #31, #35, #36, #38, #40, #43, #45, #46, #48, #50, #51, #53, #58, #59, #60, #62, #403, #404, #405 and #406). The facility managed funds for 46 residents. The facility census was 53. 1. Record review of the facility maintained Trust - Current Account Balance Report as of 11/30/2022, dated 09/01/23, showed the following residents were allowed to go into a negative balance for 11/2022. Resident Amount #11 <$9.75> #20 <$50.00> #36 <$24.11> #40 <$4.03> #43 <$0.16> #405 <$30.00> #406 <$35.74> 2. Record review of the facility maintained Trust - Current Account Balance Report as of 12/31/2022, dated 09/01/23, showed the following residents were allowed to go into a negative balance for 12/2022. Resident Amount #17 <$9.07> #20 <$65.00> #23 <$29.60> #25 <$9.11> #36 <$8.41> #38 <$2.86> 3. 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.

Based on record review and interview, the facility failed to maintain a system to ensure the resident trust fund account was managed in accordance with proper accounting principles by not maintaining an accurate accounting of all monies held in the resident trust fund account and by not reconciling each month. The facility managed funds for 46 residents. The facility census was 53. 1. Record review of the facility maintained reconciliation forms, dated August 2022 through July 2023, showed the facility attempted to reconcile by inserting numbers, to make it appear as though the reconciliation showed a zero balance for the following months. -August 2022: fund facility error $4.31, $11.87, $147.17 and $306.16; fund negative balance $28.60 and $20; fund missing funds $500; -September 2022: fund facility error $306.16; fund missing funds $500; fund unknown debit $453.39; -October 2022: fund unknown debit $453.39; -November 2022: fund unknown debit $453.39; fund check 5011 error #321; -December 2022: fund check 5011 error $321; fund negative balances $51.13; posting error-fund $645; paid…

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

Based on record review and interview, the facility failed to provide notification when the resident's trust account reached $200 less the Supplemental Security Income (SSI) resource for six residents (Residents #5, #9, #13, #27, #30 and #33). The facility managed funds for 46 residents. The facility census was 53. 1. Record review of the facility maintained Trust - Current Account Balance Report as of 07/31/2023, dated 09/07/23, showed the following residents had the following balances: Resident Amount #5 $6,455.71 #9 $10,649.83 #13 $6,983.27 #33 $5,555.45 2. Record review of the facility maintained Trust - Current Account Balance Report as of 06/30/2023, dated 09/01/23, showed the following residents had the following balances: Resident Amount #5 $12,920.39 #9 $9,601.33 #13 $6,648.48 #27 $8,610.45 #30 $5,683.66 #33 $7,529.78 3. Record review of the facility maintained Trust - Current Account Balance Report as of 05/31/2023, dated 09/01/23, showed the following residents had the following balances: Resident Amount #9 $9,027.08 #13 $6,296.31 #27 $7,107.94 #33 $6,438.45 4. Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure a clean, homelike environment for residents who resided in the facility. The facility failed to ensure walls, floors, ceilings, doors, linens, equipment, and furniture were clean and in good repair. The facility census was 53. Review of the policies received from the facility on [DATE] showed the facility did not provide policies specific to housekeeping and facility maintenance as requested. 1. Observation on [DATE] at 9:20 A.M. showed the arm rest cover on Resident #13's wheelchair was torn and rough with wood showing through the torn areas. The floor in the resident's room was dirty with a brown/black substance and debris. There was a strong urine odor in the room. There was no soap in the soap dispenser in the bathroom, and there was a used uncovered graduate on the floor with a yellowish substance in the container. During an interview on [DATE] at 9:20 A.M., the resident said he/she had asked for a new wheelchair, but he/she had not received…

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 complete comprehensive care plans for four residents (Resident #28, #30, #34, and #53), in a review of 21 sampled residents. The facility census was 53. Review of the facility policy, Comprehensive Care Plans and Baseline Care Plans, last reviewed 1/19/22, showed the following: -The purpose was to ensure the facility developed a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment; -The Comprehensive Care Plan must be completed within 14 days of admission; -Daily nursing meetings will occur Monday thru Friday with a review of the resident's medical, functional and psychosocial problems. From this meeting, information will be individualized to the resident's plan of care. On Monday morning, the resident's status will be reviewed from the weekend to ensure all areas that 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow professional standards of practice for two residents (Residents #28 and #14), in a review of 21 sampled residents. The facility failed to follow physician's orders for dressing changes to diabetic foot ulcers for Resident #28, and failed to administer medication as ordered by the resident's physician to Resident #14. The facility census was 53. Review of the facility's policy for following physician's orders, dated 7/9/21, showed the following: -The purpose of the policy was to outline procedures to ensure physician's orders were followed and that a process was in place to monitor nurses in accurately following physician's orders; -Upon receiving a physician's order via telephone, fax, written order, transcribed order, or other, it will be written on the physician's order sheet (POS); -The unit director/designated nurse would review of medication administration records and treatment administration records daily to monitor for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide Activities of Daily Living (ADL's) for five dependent residents in a review of 21 sampled residents. Staff failed to provide oral care for two residents (Residents #6 and #24) who were NPO (nothing by mouth) and received only tube feedings. Staff failed to provide complete perineal care for three incontinent residents (Resident #6, #8, and #24. Staff failed to monitor resident #50 for incontinence and/or provide incontinence care as warranted. The facility census was 53. During an interview the director of nursing said the facility did not have a policy for providing activities of daily living (ADL) care. Review of the facility policy, Gastronomy Tubes (a tube inserted directly into the stomach for nutrition), dated 8/30/23, showed the resident with a feeding tube is usually NPO. Dry mouth, dry lips and sore throat are sources of discomfort. The resident's care plan will often include frequent oral hygiene, lubricant for the lips…

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 serve the correct portion sizes as directed for residents on a low concentrated sweets (LSC)/consistent carbohyrdate (CCHO) diet for the lunch meal on 8/22/23. The facility census was 53. Review of the diet report dated 8/22/23 showed 11 residents had diet orders for a low concentrated sweets (LSC)/consistent carbohyrdate (CCHO) diet. Review of the diet spreadsheet menu for the lunch meal on 8/22/23 showed staff were to serve residents on a LSC/CCHO diet a 4-ounce portion of spaghetti with meat sauce and a #12 dip of banana pudding (2.875 ounces). During an interview on 8/22/23 at 11:50 A.M. Dietary Aide M said he/she portioned the banana pudding into bowls with a #8 (4 ounces) scoop. Observation on 8/22/23 between 11:55 A.M. and 12:40 P.M., showed [NAME] N served all residents on a LSC/CCHO diet a 6-ounce portion of spaghetti with meat sauce (instead of 4-ounce serving) and a #8 dip (4-ounce) serving of banana pudding (instead of a 2.875-ounce serving). During an interview on 8/22/23 at 2:40 P.M., Dietary…

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 maintain the prevention of communicable disease in regards to Tuberculosis (TB) (a communicable disease that affects the lungs characterized by fever, cough, and difficulty breathing) when the facility failed to ensure Tuberculin Skin Tests (TST) for four new employees (Registered Nurse (RN) A, Social Services Director, Maintenance Director, Nurse Aide (NA) G) of ten new employees reviewed, were completed in accordance with the general requirements for TB testing for long-term care employees. The ten sampled employees were hired since the previous survey. Staff failed to ensure proper infection control techniques including proper hand hygiene and proper gloving was followed while providing incontinence care for four residents (Resident #6, #8, #28, and #31) and failed to ensure one resident's (Resident #30's), urinary catheter (a tube inserted in to the bladder to excrete urine out of the body) drainage bag and tubing did not rest on 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 ensure the facility was free of pests. The facility census was 53. Review of the facility's pest policy dated 6/29/23 showed it was not specific to the facility's prevention, treatment, and/or maintenance of flies. 1. Review of Resident #50's progress note dated 7/5/23 at 11:57 A.M. showed the resident showed staff his/her right forearm which was noted to be red, swollen, and warm to touch. The forearm had a white head with brown dot in the middle. The physician was notified and orders were obtained for Keflex (oral antibiotic) and warm compresses to the affected area. Review of physician's progress note dated 7/11/23 showed on 7/5/23 resident's left forearm was hot, red, and had a brown dot in the center which looked like a spider bite. The resident was started on Keflex and warm compresses. Assessment revealed a boil on his/her left forearm. Review of resident's Minimum Data Set, (MDS) a federally mandated assessment instrument completed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to provide reasonable accommodation of individual needs by ensuring resident's call lights were in reach at all times for two residents (Resident #24 and #31) in a review of 21 sampled residents. The facility census was 53. The facility did not have a policy regarding accessibility of call lights. 1. Review of Resident #24's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/25/23, showed the following: -Moderately impaired cognition; -Totally dependent on two staff for transfers. Review of the resident's care plan, dated 7/27/23, showed the following: -Totally dependent with all activities of daily living (ADLs); -Required assist of two staff for bed mobility and transfers; -The resident required a safe environment with a working and reachable call light and personal items in reach. Observation on 8/21/23 at 11:40 A.M., showed the resident lay in his/her bed. His/Her call light lay 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 proper care for two sampled residents (Residents #6 and #24) who had gastrostomy tubes (a tube inserted through the abdominal wall directly into the stomach to provide nutrition), in a review of 21 residents. The facility failed to label the nutritional bottles, failed to check placement and residual prior to administering medications, failed to properly administer tube medications, and failed to ensure Resident #24's bed was elevated as appropriate while he/she received nutrition through the feeding tube. The facility census was 54. Review of the facility policy, Gastrostomy Tubes, dated 1/19/22, showed the following: -The resident with a feeding infusing should not lie flat. The head of the bed should be elevated. Some procedures will need to be changed slightly for the resident with a feeding infusing. For example, an occupied bed cannot be flattened to change the linen; -When multiple medications are scheduled for…

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

Based on interview and record review, the facility failed to ensure two nurse aides (NA D and NA E), completed a nurse aide training program within four months of their employment in the facility. The facility census was 94. The facility did not have a policy on certification of nurse aides. 1. Review of the facility Nurse Aide Training Log showed NA D's date of hire was February 2021 (no specific day noted). He/She began NA responsibilities on 4/3/22. NA D enrolled in a nurse aide training program in March 2023 (within a few days of the 7th). There was no documentation to show if the training was complete or if NA D was certified. During interview on 8/21/23 at 3:00 P.M. NA D said he/she had been employed at the facility as an NA for seven months. He/She had completed the online course and could test soon. 2. Review of the facility Nurse Aide Training Log showed NA E's date of hire was 12/19/22 (he/she had previously been employed with a hire date of 8/8/19). NA E enrolled in a nurse aide training program on March 7th, 2023. There was no documentation to show if the training was…

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

Based on observation, interview, and record review, the facility failed to prepare and serve bread and butter for any resident as directed in the approved menu. The facility census was 59. Review of the facility policy Requirements for Dietary, dated 11/28/16, showed menus must be followed. Review of the menu for the noontime meal on 12/10/19 showed staff was to serve spaghetti and meatballs, steamed vegetables, pineapple upside down cake, and bread and butter. Observations on 12/10/19 between 11:28 A.M. and 1:03 P.M. showed staff served meal trays to all the residents. Staff did not serve bread and butter to any resident. During interview on 12/10/19 at 12:46 P.M., [NAME] S said staff usually served garlic bread with the meal that was being served, but there was none. During interview on 12/10/19 at 2:59 P.M., the dietary manager said it was just oversight that staff did not serve the bread and butter with the noon meal. She expected staff to serve bread and butter if it is on the menu. During interview on 12/10/19 at 3:24 P.M., the administrator said he expected staff to serve…

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

Based on observation and interview, the facility failed to ensure the ovens were free of buildup and debris; failed to ensure the ceiling in the walk-in cooler was clean and free of a mold-like substance; and failed to ensure the serving trays were dry before storing them for use. The facility census was 59. 1. Observation on 12/10/19 at 9:43 A.M. in the both ovens showed a heavy buildup of debris on the bottoms of each oven. Observation on 12/10/19 at 9:50 A.M. showed the ceiling in the walk-in cooler had a basketball sized area that was covered with a black flaky mold-like substance. A three-tier cart with cottage cheese covered with plastic was stored below the area. Observation on 12/10/19 at 11:38 A.M. showed the serving trays had standing water on them. During interview on 12/10/19 at 2:59 P.M., the dietary manager said she was not aware of the build-up in the ovens. She would expect the ovens to be clean. The ovens were on a cleaning schedule and she was not sure if staff had cleaned them. She had been gone from the facility on leave. She was not aware staff was putting 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 ensure staff treated three residents (Resident #9, #21 and #35) in a sample of 17 residents, and two additional residents (Resident #10 and #49) with dignity and respect when staff made inappropriate comments to residents during care and failed to provide meal service in a dignified manner by serving meals on Styrofoam plates with plastic silverware. The facility census was 59. 1. Review of the facility's policy Resident Rights, undated, showed the following: -Residents shall be treated with consideration, respect and full recognition of his/her dignity and individuality, including privacy in treatment and care of his/her personal needs; -All persons, other than the attending physician, facility personnel necessary for any treatment or personal care, or the Missouri Division of Aging or Department of Mental Health staff, as appropriate, shall be excluding from observing a resident during any time of examination, treatment or care unless…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to provide reasonable accommodation of individual needs by providing a comfortable chair for 21 out of 23 of the residents on the secured unit, and failed to provide over-bed tables for two residents (Resident #21 and #258) in a review of 17 sampled residents and three additional residents (Resident #57, #26, and #28) on the secured unit. The facility census was 59. 1. During an interview on 12/17/19, at 10:41 A.M., the administrator said the facility did not have a policy on providing a comfortable chair or over the bed tables. 2. Observation on 12/11/19, at 6:57 A.M. in the secured unit showed the following: -Two residents resided in room [ROOM NUMBER], there was one dining room style chair (straight chair without arm rest) for bed 2, and no over-bed tables; -Two residents resided in room [ROOM NUMBER], there was one dining room style chair for bed 2, and noover-bedd tables; -Two residents resided in room [ROOM NUMBER], there were no chairs or over-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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain the facility walls, floors, fixtures and exhaust vent covers in restrooms to be clean and in good repair. The facility census was 59. 1. Observation on 12/9/19 at 10:16 A.M. in resident room [ROOM NUMBER] showed the paint on the wall next to the bed closest to the door was was marred and scraped in a section that measured approximately 24-inches wide with exposed drywall. The wall behind the bed nearest the window was also marred with exposed drywall. Observation on 12/9/19 at 10:23 A.M. and 12/10/19 at 8:36 A.M., showed the flooring in the bathroom for resident room [ROOM NUMBER] was discolored and was yellow and stained around the toilet. Observation on 12/9/19 at 12:18 P.M. showed a 4-foot long section of cove base trim in the main dining room outside the dirty dish room door had come loose from the wall and lay on the floor. The dry wall was exposed and crumbling with holes in the wall. Observation on 12/10/19 at 10:06 A.M. showed unpainted…

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 use proper technique during gait belt (canvas belt placed around the resident's waist to assist with ambulation and transfers), transfers for three residents (Residents #14, #47 and #159), when the resident's did not bear weight, or bore only minimal weight, during transfers. The facility staff failed to employ appropriate methods for repositioning for one resident (Resident #14), when staff lifted and repositioned the resident under his/her arms or assisted to a sitting position by pulling on his/her arms and back of neck. The facility failed to properly propel two sampled residents (Resident #42, and #32) and three additional residents (Resident #2, #56, and #50), by transporting residents' in wheelchairs without foot pedals. The facility census was 59. 1. Review of the facility's policy on precautionarymeasuree for gait beltapplicationn and usage, reaffirmed 4/6/17, showed the following: -The purpose of this policy is to ensure…

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 comprehensively assess pain, provide PRN (as needed) pain medication, and intervene when the resident exhibited crying out during cares for two residents (Resident #27 and #159 ) in a review of 17 sampled residents. Facility staff also failed to accurately assess and document one alert resident (Resident #21)'s pain level. The facility census was 59. 1. Review of the facility policy Pain Management dated April 6, 2017, showed the following: -All residents in the facility will have a pain assessment upon admission and quarterly and as needed to address and determine the following: presence of pain, origin of pain, if the pain was acute/chronic, frequency, changes in baseline behavior due to pain, acceptable pain level, identify the resident's current pain management plan of care, effectiveness of current pain management plan of care, and changes required in the plan of care to help lower the resident's pain intensity to no pain or their…

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 attempt a gradual dose reduction (GDR), or document a clinical reason to justify the need to continue psychotropic (a chemical substance that changes brain function and results in alterations in perception, mood, consciousness or behavior) medications for two residents (Resident #21 and #40) in a review of 17 sampled residents. The facility also failed to include indications for psychotropic medications for one resident (Resident #17). The facility census was 59. 1. During an interview on 12/17/19, at 10:41 A.M., the administrator said the facility did not have a policy on psychotropic drug use and monitoring. 2. Review of Resident #21's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/9/19 showed the following: -Cognitively intact; -Received antipsychotic medication seven of the last seven days; -Received antipsychotic medication on a routine basis only; -A GDR has not been attempted 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 serve food that was palatable and at a safe and appetizing temperature. The facility census was 59. 1. Review of the facility's policy Requirements for Dietary, dated 11/28/16, showed each resident shall receive food prepared by methods that conserve nutrition value, flavor and appearance; food and drink that is palatable, attractive, and a safe and appetizing temperature. Review of the facility's undated policy Food Temperatures showed acceptable serving temperatures for meats, entrees and vegetables was greater than 140 degrees Fahrenheit, and temperature of hazardous salads and desserts was less than 41 degrees Fahrenheit. 2. During interview on 12/9/19 at 10:28 A.M., Resident #12 said the food tasted terrible. There was no seasoning and he/she was used to home cooked food. During interview on 12/9/19 at 10:36 A.M., Resident #3 said the food was terrible and did not taste good. The food that was to be served hot was served warm. Cottage cheese had been served warm for the last week. During interview 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 ensure that staff washed their hands after each direct resident contact and when indicated by professional standard of practice during personal care for three residents (Resident #14, #47, and #159) in a sample of 17 residents; failed to ensure infection control measures were appropriately followed when staff failed to properly disinfect a urine soiled mattress prior to applying clean linen for one resident (Resident #14) ; failed to disinfect a glucometer (device used to check blood glucose levels) used for multiple residents according to acceptable infection control practice for four additional residents (Resident #22, #45, # 37 and #33); and failed to properly disinfect the rubber stopper of an insulin pen prior to medication administration for one additional resident (Resident #33). The facility census was 59. 1. Review of the facility's policy on hand washing, reaffirmed 4/6/17, showed the following: -The use of gloves does not 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to offer or administer eligible residents with the pneumococcal vaccine as recommended by the current Centers for Disease Control (CDC) guidelines, for six residents (Resident #14, #21, #27, #32, #52 and #159) in a sample of 17 residents and five additional residents (Resident #2, #10, #11, #50, and #54). The facility census was 59. 1. Review of the facility's policy for Influenza and Pneumococcal Immunizations, reaffirmed April 6th, 2017, shows the following: -The purpose of this policy is to ensure that all residents residing in the facility are offered influenza and pneumococcal immunizations to prevent infection and the spread of communicable disease; -The resident or their legal representative will be told the pneumococcal immunization will be offered up on admission and a second pneumococcal immunization may be recommended after five years from the first immunization. The pneumococcal immunization will not be given if the immunization is medically…

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 adequate dining space on the secured unit where 23 residents resided. The facility census was 59. 1. During an interview on 12/11/19 at 3:00 P.M., the administrator said the facility did not have a policy regarding dining space. 2. Review of the facility's census showed 23 residents resided in the secured unit. 3. Observation on 12/9/19, at 12:08 P.M., an unidentified staff member said, They are taking chairs out of the dining room, and we don't have enough to another staff member. Observation on 12/9/19, at 12:09 P.M., showed the following: -13 residents were in the dining room on the secured unit; -No chairs were available for other residents to sit down; -Resident #17 sat in a wheelchair; -Resident #37 stood in the corner playing a game, there was no chair available for him/her to sit down; -11 dining room chairs present and in use in the dining room; -Three spots available at the tables without a resident or chair that would be difficult to get to related to lack of space. During an interview 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 documentation of a medical diagnosis that warranted the use of a restraint prior to initiation, assessment and monitoring for the use of physical restraints, including a pommel cushion (a cushion with an upward-projecting protuberance at its front part that prevents a wheelchair dependent resident from sliding down and possibly falling out of a wheelchair), a seat belt to prevent rising from a wheelchair and a low bed to prevent rising from a bed, that were implemented as interventions to prevent falls for two residents (Resident #14 and #32), in a review of 17 sampled residents. The residents could not easily and intentionally rise from a wheelchair or exit a low bed without staff intervention. The facility census was 59. 1. Review of the facility admission packet showed the resident has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat 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.