Delmar Gardens Of Chesterfield

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, review of the Centers for Disease Control (CDC) guidelines, and facility policy review, the facility failed to: 1. Wear appropriate personal protective equipment (PPE) when providing care to residents on transmission-based precautions. 2. Doff (take off) soiled PPE prior to exiting the resident's room. 3. Complete resident testing upon new positive cases of COVID-19 in the building. 4. Complete contact tracing for staff that were in close contact with COVID-19 positive residents or exposed to Respiratory Syncytial Virus (RSV) positive residents 5. Provide evidence of staff testing done during an outbreak of COVID-19. 6. Ensure appropriate cohorting of residents within close contact to other COVID-19 and RSV positive residents. This affected 49 (Residents (R) 116, R46, R121, R65, R81, R72, R13, R157, R14, R96, R67, R172, R88, R92, R134, R221, R111, R173, R156, R174, R83, R130, R175, R158, R114, R176, R4, R177, R159, R131, R273, R272, R178, R28, R179, R108, R102,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure third party liability (TPL) forms were completed within 30 days for the final accounting for residents who expired. This affected 15 residents who expired and had money in their accounts (Residents #509, #505, #502, #503, #511, #504, #501, #508, #510, #506, #512, #517, #513, #516, #515). The sample size was 17. The census was 179. 1. Review of Resident #509's medical record showed the following: -Effective/Expired on [DATE]; -Ending balance of $927.44; -No documentation of a TPL. 2. Review of Resident #505's medical record showed the following: -Effective/Expired on [DATE]; -Ending balance of $150.07; -TPL completed on [DATE]. 3. Review of Resident #502's medical record showed the following: -Effective/Expired on [DATE]; -Ending balance of $4238.47; -TPL completed on [DATE]. 4. Review of Resident #503's medical record showed the following: -Effective/Expired on [DATE]; -Ending balance of $3768.40; -TPL completed on [DATE]. 5. Review of 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 observations, staff and resident interviews, record reviews, and review of monthly Resident Council meeting minutes, the facility failed to ensure sufficient staffing to meet the needs of the 180 residents in the facility. Several residents and staff members voiced concerns regarding sufficient staffing, and the facility exhibited failures related to a lack of sufficient staffing throughout the survey. Findings include: A policy on staffing was requested but was not provided prior to survey exit. Review of the monthly Resident Council meeting minutes, provided on paper, revealed concerns of call lights taking too long to be answered were brought up in January 2024, November 2023, October 2023, and June 2023. During Initial Pool interviews and observations, four residents voiced concerns related to a lack of sufficient staffing: -During an interview with a resident who wished to remain anonymous on 02/05/24 at 11:28 A.M., the resident stated there was not enough staff available to answer call lights, especially at night. -During an interview on 02/05/24 at 11:57 A.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, review of Resident Council Meeting notes, and policy review, the facility failed to serve hot foods at palatable temperatures for seven of 40 sampled residents (Resident (R) 6, R64, R57, R75, R123, R143, and R146). This failure had the potential to contribute to decreased intake by residents. Findings include: A review of the facility policy titled Enhancing the Dining Experience, from the Dining Services policy and procedures manual, dated 2014, number 11 of 12 listed tasks stated that the meals were to be served in an attractive manner; served at the appropriate temperature; served according to safe food handling practices, and meets the residents' individualized needs. Review of the Resident Council Meeting notes, provided by the facility, revealed two previous food temperature group complaints were recorded on 07/24/23 and 11/27/23. During observation of the lunch meal service on 02/06/24 at 12:30 P.M., R64 was served lunch and ate less than 25 percent of his/her meal. R64 stated his/her food did not look appetizing or taste good. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and policy review, the facility failed to ensure the advance health care directive of one (Resident (R) 147) of six residents reviewed for advance directives was honored. This failure had the potential to result in unwanted provision of cardio-pulmonary resuscitation (CPR) resulting in possible pain, injuries such as broken ribs, and altered mental status. Findings include: Review of the undated Advance Directives Policy revealed, Upon admission, identify if the resident has an advance directive and if not, determine if the resident wishes to formulate an advance directive . Resident wishes will be communicated to the staff via the care plan and (identify facility protocol for communication of advance directives either in written or oral format) and to the resident physician. Review of R147's Resident Face Sheet under the Resident tab in the electronic medical record (EMR) revealed he/she was admitted to the facility on [DATE] with diagnoses including Alzheimer'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 record review, interviews, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to conduct a comprehensive assessment including assessment of mood and daily activity preference for two (Resident (R) 100 and R147) of 40 sample residents. These failures created a potential for specific resident needs related to mood and/or daily and activity preference to go unidentified. Findings include: Review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, accessed at https://www.cms.gov/files/document/finalmds-30-rai-manual-v11811october2023.pdf, revealed, Mood: Intent: The items in this section address mood distress and social isolation. Mood distress is a serious condition that is underdiagnosed and undertreated in the nursing home and is associated with significant morbidity. It is particularly important to identify signs and symptoms of mood distress among nursing home…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to conduct a quarterly assessment including assessment of cognitive patterns and mood for one (Resident (R) 118) of 40 sampled residents. These failures created a potential for specific resident needs related to cognition and mood to go unidentified. Findings include: Review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, accessed at https://www.cms.gov/files/document/finalmds-30-rai-manual-v11811october2023.pdf, revealed, Cognitive Patterns: Intent: The items in this section are intended to determine the resident's attention, orientation, and ability to register and recall new information and whether the resident has signs and symptoms of delirium. These items are crucial factors in many care-planning decisions . Attempt to conduct the interview with ALL residents. This interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an accurate Level 1 pre-screening of a resident for a mental disorder (MD) or intellectual disability (ID) prior to admission to the facility was completed for one of one resident (Resident (R) 23) reviewed for Level 1 (one) Pre-admission Screening and Resident Review (PASARR). Findings include: Review of R23's ''Face Sheet'' located in the electronic medical record (EMR) under the ''Profile'' tab, revealed an admission date of 12/15/17 and included the following diagnoses: anxiety disorder, major depressive disorder, and bipolar disorder. Review of R23's annual ''Minimum Data Set (MDS),'' located in the EMR under the ''MDS'' tab, with an Assessment Reference Date (ARD) of 11/06/23 revealed R23 had a ''Brief Interview for Mental Status (BIMS)'' score of eight out of 15, which indicated he was moderately cognitively impaired. The MDS indicated R23 had anxiety disorder and manic depression. Review of R23's EMR did not include a Level 1 PASARR.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and policy review, the facility failed to ensure two (Resident (R) 100 and R147) of four residents reviewed for activities of daily living (ADLs) received assistance with incontinence care and/or using the toilet as needed. These failures created a potential for skin problems, urinary tract infections, or increased incontinence for these two residents. Findings include: Review of the Urinary Incontinence Management policy, dated June 2021, revealed, AII residents will receive perineal care, as needed, in the morning before breakfast. every evening with evening care at bedtime, as needed after bowel movement or urination, and each time the resident is incontinent. The policy failed to address the expectation for rounding to check for incontinence and change if needed at least every two hours. 1. Review of R100's Resident Face Sheet under the Resident tab in the electronic medical record (EMR) revealed he/she was admitted to the facility on [DATE] with diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure two (Resident (R) 147 and R151) of five residents reviewed for activities were assessed for activity interests and needs and received a program of activities to meet their needs. These failures placed R147 and R151 at risk for increased feelings of depression, helplessness, and boredom. Findings include: A policy on provision of activities was requested from the facility; however, was not provided prior to survey exit. 1. Review of R147's Resident Face Sheet under the Resident tab in the electronic medical record (EMR) revealed he/she was admitted to the facility on [DATE] with diagnoses including: Alzheimer's disease with anxiety, depression, and repeated falls. Review of R147's admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 12/13/23 and located in the RAI (Resident Assessment Instrument) tab of the EMR, revealed he/she was unable to answer the Brief Interview for Mental Status (BIMS) and staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and policy review, the facility failed to ensure the physician acted upon the notification of irregularities in the medication regimen for one (Resident (R) 53) of five residents reviewed for unnecessary medications. This failure created the potential for unnecessary antipsychotic medication use, which could lead to adverse consequences such as over-sedation, mental status changes, or involuntary movements. Findings include: Review of the Behaviors Using Person -Centered Care, Accommodating policy, dated February 2021, revealed, Psychopharmacological therapy Charting requirements [for] Antipsychotics and/or any psychotherapeutic agents (other than antipsychotics, sedative/hypnotics: Targeted harmful behaviors must be defined and the occurrence of such documented quantitatively every shift on flow sheet. A policy addressing the Pharmacist's drug regimen review and physician response was requested but not provided prior to survey exit. Review of R53's Resident Face Sheet under…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and policy review, the facility failed to ensure the drug regimen of one (Resident (R) 53) out of five residents reviewed for unnecessary medications contained adequate indication for use of an anti-psychotic medication. This failure placed R53 for potentially avoidable adverse effects of the drug, including over-sedation, mental status changes, or involuntary movements. Findings include: Review of the Behaviors Using Person -Centered Care, Accommodating policy, dated February 2021, revealed, Criteria for identifying a problem behavior: A danger or safety risk to self/others . The potential risks of Antipsychotic Drugs are: Movement disorders, e.g., tardive dyskinesia, EPS symptoms; Hypotension; Sedation; Weight gain; Blurred vision; Dry mouth; Constipation; Urinary retention; Tachycardia; Increase risk for falling and fractures; Stroke; [and] Associated hospitalizations/death . Inappropriate use for antipsychotic medications: Wandering; Poor self-care; Restlessness; Impaired…

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 review of the United States (US) Food and Drug Administration (FDA) Food Code, the facility failed to ensure dishware stored at the ice machine was covered or inverted for storage in a clean, dry location not exposed to dust or other potential contamination. Findings include: Review of the 2022 US FDA Food Code under Storing: Equipment, Utensils, Linens, and Single-Service and Single-Use Articles revealed cleaned equipment and utensils shall be stored in a clean, dry location; where they are not exposed to splash, dust, or other contaminants; and shall be stored covered or inverted. During an interview with Resident (R) 103's family member (F3) on 02/06/24 at 12:21 P.M., he/she stated his/her family member did not like to drink from the hydration mugs, because he/she did not think they were clean. F3 stated he/she brought R103 drinks from home. During on observation on 02/09/24 at 2:05 P.M. of the room containing the facility ice machine and the employee time clock, revealed a large plastic shelving unit in the corner of the room. The shelving…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and policy review, the facility failed to ensure one resident's room (room [ROOM NUMBER]-1) was clean and in good repair for one room observed on the 200 Hall. Findings include: Review of the Environmental Cleaning and Infection Control Policy effective date March 2020 under Housekeeping Resident Room, under Procedures item 5 revealed Staff should promote a homelike living environment for all residents. Under Bathroom Cleaning Clean the toilet with disinfectant (including the tank, outside and inside the bowl) .Clean the sink, tub/shower, including all tile inside and around the shower walls and floor . During an observation of room [ROOM NUMBER]-1 on 02/08/24 at 10:15 A.M., the resident who resided in the room said his/her room, bathroom, and shower had not been cleaned for several weeks. In addition, the resident complained that the floor in her room and bathroom had a sticky film. During an observation on 02/09/24 at 10:20 A.M., the floor in room [ROOM NUMBER]-1 and in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents were provided with dignity and respect by failing to administer insulin injections in a private area for three residents (Residents #341, #340 and #342) and by failing to sit next to one resident while assisting the resident with a meal (Resident #77). The sample was 24. The census was 155 with 137 residents in certified beds. 1. Review of Resident #341's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/30/20, showed: -admission date of 12/30/15; -Severe cognitive impairment; -Diagnoses included diabetes, dementia, Alzheimer's disease and depression; -Insulin injections received 7 of 7 days. Review of the resident's November 2021 medication administration record (MAR), showed: -An order, dated 12/10/20, for insulin aspart (short acting insulin) insulin pen; 100 units per milliliter (ml); administer 30 units subcutaneous (under the skin) three times…

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 follow their transfer or discharge policy by not providing to the resident and/or their representative the written transfer notice at the time of the resident's facility initiated transfer, for 4 residents (Residents #84, #72 #135, and #71). The sample was 24. The census was 155 with 137 in certified beds. Review of the facility's Hospital Transfer of Resident policy, revised January 2019, showed: -Purpose: To provide prompt and safe transfer of resident from the facility and to ensure continuity of care through provision of pertinent resident information; -Procedure: An interact nursing home to hospital transfer form (tool used to help the nursing home clearly communicate a wide range of critical information about the resident to emergency room) observations will be completed by the nurse unless it is an urgent 911 and/or time doesn't allow; -Notify resident representative and document that their intent to have resident transferred to the hospital;…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to inform the resident and/or resident representative of the bed hold requirements at the time of transfer to the hospital for various medical reasons for four of the 24 residents sampled (Resident #84, #72, #135, and #71). The census was 155 with 137 residents in certified beds. Review of the facility's Bed Hold Policy, undated, showed: -Purpose: To notify the resident and/or representative(s) of the Bed Hold Policy in writing at the time of admission, upon change or revision and when transferred to a hospital or during therapeutic leave, as well as the intent for readmission according to state and federal regulations; -Procedure: The facility will also give a copy of this policy to the resident and/or representative if transferred to a hospital. In addition, the facility will call the representative, if applicable, within 24 hours of the transfer or leave. 1. Review of Resident #84's Minimum Data Set (MDS), a federally mandated assessment instrument…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a comprehensive assessment of residents at least annually for nine residents (Residents #20, #5, #339, #284, #338, #136, #28, #335 and #334). The sample was 24. The census was 155 with 137 in certified beds. 1. Review of Resident #20's medical record, showed admitted on [DATE]. Review of the residents Minimum Data Set (MDS, a federally required assessment instrument completed by facility staff) record, showed: -An annual assessment dated [DATE]; -A quarterly assessment dated [DATE]; -No annual assessment completed [DATE]. 2. Review of Resident #5's medical record, showed admitted on [DATE]. Review of the resident's MDS record, showed: -An annual assessment dated [DATE]; -No comprehensive assessment completed [DATE]. 3. Review of Resident #339's medical record, showed admitted on [DATE]. Review of the resident's MDS record, showed: -A change in condition assessment dated [DATE]; -No comprehensive assessment completed [DATE]. 4. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assess a resident using the quarterly review instrument not less frequently than once every 3 months for six residents (Residents #20, #41, #8, #284, #335 and #334). The sample was 24. The census was 155 with 137 in certified beds. 1. Review of Resident #20's medical record, showed admitted on [DATE]. Review of the residents Minimum Data Set (MDS, a federally required assessment instrument completed by facility staff) record, showed: -An annual assessment dated [DATE]; -A quarterly assessment dated [DATE]; -No quarterly assessment completed [DATE]. 2. Review of Resident #41's medical record, showed admitted on [DATE]. Review of the resident's MDS record, showed: -An admission assessment dated [DATE]; -No quarterly assessment completed [DATE]. 3. Review of Resident #8's medical record, showed admitted on [DATE]. Review of the resident's MDS record, showed: -An admission assessment dated [DATE]; -No quarterly assessment completed [DATE]. 4. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized care plans, to address the specific needs of the residents, for five of 24 sampled residents (Residents #61, #71, #135, #11 and #84). The census was 155 with 137 residents in certified beds. 1. Review of Resident #61's admission Minimum Data Set (MDS, a federally mandated assessment completed by facility staff), dated 10/15/21, showed: -Moderate cognitive impairment; -No behaviors; -Required the assistance of one staff for walking, transfers, dressing, toileting and personal hygiene; -Always continent of bowel and bladder; -Diagnoses included high blood pressure, diabetes, dementia and depression. Review of the resident's November 2021 electronic physician order sheet (ePOS), showed: -An order, dated 10/20/21, for palliative care (specialized medical care for people living with a serious illness); -An order, dated 11/6/21, for female certified nurse aides (CNA) only for all shifts.…

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 assess two residents for medication self-administration and obtain physician's orders (Resident #384 and #492), obtain physician's orders for a wanderguard (a device worn by a resident that triggers alarms and can lock monitored doors to prevent the resident leaving unattended) for one resident (Resident #61) and obtain oxygen orders for one resident utilizing oxygen (Resident #33). Facility staff also failed to provide showers as ordered for one resident (Resident #1), provide treatments as ordered for two residents (Resident #203 and #53) and perform weekly skin assessments for one resident (Resident #53). The sample was 24. The census was 155 with 137 residents in certified beds. 1. Review of the medication administration policy, dated January 2021, showed residents are allowed to self-administer medication specifically ordered by the attending physician. 2. Review of the facility's self-administration policy, dated 6/21, showed: -Self…

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 were knowledgeable about hazardous chemical protocol with utilization of safety data sheets (SDS) when one resident (Resident #339) ingested alcohol-based hand sanitizer. The facility staff failed to lock the medication/treatment cart when not in direct sight of the staff, failed to complete a smoking assessment for one resident (Resident #284) and failed to complete fall follow up for four residents (Residents #61, #490, #487 and #5). The sample was 24. The census was 155 with 137 residents in certified beds. Review of the facility's Emergency Safety Procedures for Hazardous Chemicals policy, effective November 2021, showed: -Purpose: Manage potential or actual exposure to hazardous material. Provide directives regarding the best way to respond quickly and appropriately. First aide procedures include inhalation, ingestion, skin, and eye; -Procedure: -Ensure the resident is safe and free of harm; -Notify the charge nurse;…

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 quality of the labs obtained when they failed to meet the applicable requirements for obtaining their own labs. The facility failed to ensure accurate results of the blood glucose test machines by not completing daily quality control checks and then used expired control check solution. The census was 155 with 137 in certified beds. Observation of the 700 hall treatment cart on [DATE] at 1:45 P.M., showed two boxes of control solution (solution used to test the accuracy of the blood glucose machine). The two boxes showed expiration dates of [DATE] and [DATE]. Each box had two bottles of control solution, one bottle of normal solution and one bottle of high control solution, used to test the accuracy of the glucometer. During an interview on [DATE] at 1:45 P.M., Licensed Practical Nurse (LPN) LL said he/she wasn't sure which control solution was used because the night shift does that. LPN LL then took the two expired boxes 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure staff would follow the resident's wishes to request or refuse lifesaving treatments in the event the resident was found with no signs of life, by failing to ensure the resident's code status was consistently documented in the medical record, for two residents (Residents #134 and #136). In addition, the facility failed to have a written policy to implement advanced directives. The sample was 24. The census was 155 with 137 in certified beds. During an interview on [DATE] at 11:20 A.M., the administrator said the facility does not have an advance directive policy. 1. Review of Resident #134's electronic medical record, showed: -An electronic face sheet with an admission date of [DATE]; -A physician order dated [DATE], for cardio pulmonary resuscitation (CPR, lifesaving measures are to be performed); -No documentation the resident's wishes for code status were discussed with the resident or resident's representative and/or if the resident's wishes…

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 provide the appropriate Center for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advance Beneficiary Notices (SNF ABN) for two of two residents sampled as part of the Beneficiary Notice review who remained in the facility after being discharged from skilled services (Residents #7 and #43). The census was 155 with 137 residents in certified beds. 1. Review of the list of residents discharged from skilled services within the last six months, provided by the facility, showed Resident #7 discharged from skilled services on 7/5/21, and remained in the facility. Review of the notices provided to the resident, showed no SNF ABN notice provided. 2. Review of the list of residents discharged from skilled services within the last six months, provided by the facility, showed Resident #43 discharged from skilled services on 10/9/21, and remained in the facility. Review of the notices provided to the resident, showed no SNF ABN notice provided. 3. During an interview on 11/17/21 at 5:15 A.M., the administrator said 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 record review, the facility failed to implement their grievance policy by not ensuring a prompt resolution to a grievance regarding a missing tablet computer for one resident (Resident #338). The sample was 24. The census was 155 with 137 residents in certified beds. Review of the facility's Grievance Procedure, reviewed June 2021, showed: -Purpose: Residents and resident representative(s) are always encouraged to visit with administration any time they have input or concerns. In the majority of instances, the concern will be resolved. For those wishing to file a grievance, the following procedure would apply; -Procedure: -Any resident or resident's representative who wishes to file a grievance in regards to care and treatment which has been furnished (or not furnished), conditions, or violations of rights while under the care of the facility or any other concern is welcome to submit a written account of the details of the grievance to the administrator without fear of discrimination or reprisal. In the event the resident is unable to do so in writing, he/she…

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 acceptable nursing practice when staff failed to provide treatments as ordered by the physician for one resident who had a Stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible but the bone, tendon or muscle is not exposed) Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) (Resident #336) and failed to routinely assess one resident who was at risk for developing pressure ulcers (Resident #84). The sample was 24. The census was 155 with 137 in certified beds. Review of the facility's Wound Care Protocol, revised 8/2018, showed: -Goals of assessment: Provide uniform description, facilitate communication among staff, adequate monitoring of progress or deterioration; -How to assess/document: Initially assess the ulcer(s) for location, stage, size, sinus tracts, undermining, tunneling, exudate, necrotic tissue, the presence or absence of granulation…

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 residents are free from any significant medication errors, for one resident (Resident #28) who was administered two different insulins more than two hours after they were ordered to be administered. The census was 155 with 137 in certified beds. Review of the facility's medication administration policy, revised January 2021, showed: -Medications are to be given at the time ordered, within sixty minutes before or after designated time, or according to liberalized medication pass time. Review of Resident #28's electronic Physician Order Sheet (ePOS) showed: -An order dated 9/28/20, for Lantus-Solostar U-100 (long-acting insulin), 28 units twice a day, 7:30 A.M. and 4:30 P.M.; -An order dated 7/6/21, for Humalog Kwikpen Insulin (insulin lispro, short acting insulin), 14 units twice a day, morning med pass 7:30 A.M., and noon pass 11:30 A.M.; -An order dated 8/2/21, to check the resident's blood sugar before meals (AC) and at bedtime (HS) with times listed: 7:30 A.M., 11:30 A.M., 4:30 P.M., and 8:00 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 establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the transmission of infection, when staff failed to clean glucometer machines (used to check blood sugar levels) before and/or after use and failed to clean the injection site prior to administering an insulin injection for two residents (Residents #134, and #75). The sample was 24. The census was 155 with 137 in certified beds. 1. Review of the facility's Medication Administration policy, dated January 2021, showed: -Wash your hands before and after each resident contact. An alcohol based wash may be substituted; -The policy did not address injectable medication such as insulin. Review of #134's medical record, showed: -Diagnoses included concussion, diabetes and peripherally inserted central catheter (PICC, a tube/catheter inserted into a vein for medication administration). -A care plan revised, 11/18/21, showed: -Problem: Resident admitted with a PICC line to left upper…

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.