Livingston Manor Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to establish and maintain a system that assured a full and complete, separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf when monthly personal funds reconciliation showed a negative balance and when the facility failed to reimburse the residents and/or their responsible party after the resident was discharged .This affected one of 12 sampled residents (Resident #45). The facility census was 31. Review of the facility's Conveyance of Resident Funds policy dated March 2021 showed:-Any funds on deposit with the facility are refunded to the resident, the resident representative, or the resident's estate, upon discharge, eviction or death as applicable;-The resident's personal funds and a final accounting of funds are returned to the resident, the resident's representative or to the resident's estate as, applicable, with in 30 days from the date 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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, when the facility failed to have a documented water management program. The facility census was 31. Review of the monitoring water supply to minimize outbreaks of Legionella Bacteria Contamination policy, dated 12/12/2019, showed:-It is the policy of the facility to maintain water management controls through the use of risk assessments, water management program and water management program team meetings so as to minimize the possibility of a Legionella outbreak in residents through contamination of the facility water system. During an interview on 08/20/2025 at 11:35 A.M. The Maintenance Supervisor said: - He tests the waters PH monthly;- He does not perform Legionella testing;- He does not document a water management plan with interventions or risk assessments;

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed protect one sampled residents (Resident #1) right to be free from physical abuse when resident (Resident #2) hit Resident #1 in the head. The facility staff did not place Resident #2 on increased monitoring until the resident was moved to the secured unit six days after the event. The facility census was 37. Review of the facility's abuse policy, titled Abuse, Neglect and Exploitation Policy, dated 1/31/24 showed: -It is the policy of the facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. -Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Instances of abuse of all residents,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facilty staff failed to maintain standard infection control precautions when staff did not perform hand hygiene with glove changes during wound care for two residents (Resident #1 and #2). Additionally, staff did not wear a personal protective gown when assisting with wound care for Resident #2 when the resident was on Enhanced Barrier Precautions (EBP). The facility did not have gowns near or outside of the resident rooms. The facility did not obtain a physicians order to implement EBP when Resident #1 and #2 had wounds. This deficient practice affected two of two sampled residents. The facility census was 33. Review of the facility policy titled, Hand Hygiene, dated 1/1/24 showed: - Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of Practice; - The use of gloves does not replace hand hygiene; - Perform hand hygiene prior to putting on gloves, and immediately after removing gloves. 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 observation, record review, and interview the facility failed to store, prepare, and serve food in accordance with professional standards of food service safety when staff failed to use sanitary practice of washing hands and turning off faucet handle with same towel, failed to date food items, failed to check and record temperatures of the refrigerator and freezer units daily, failed to check the dishwasher twice daily prior to washing dishes, failed to temperature check all foods being served to residents, failed to store personal items away from food, and failed to complete daily food temperature log prior to meal service. The facility census was 29. 1. Review of facility policy, proper hand washing and glove use, dated 2020, showed: -All employees will use proper hand washing procedures and glove usage in accordance with State and Federal sanitation guidelines. -Proper procedure for washing hands is as following: a. Turn on water as hot as comfortable. b. Wet hands and apply soap. c. Scrub 15 to 20 seconds or more: getting under nails, between fingers, and all exposed…

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 residents with dignity and respect when staff did not ask each resident before applying clothing protectors to them in North and South dining rooms, stood while assisting four sampled residents with eating (Residents #14, #7, and #29), when staff left a clothing protector on resident before and after meals (Resident #14) and when staff did not provide privacy when was left exposed to hallway while only wearing a brief and T-shirt. (Residents #3). Additionally, the facility failed to ensure staff cared for residents in a dignified manner when they obtained blood sugars and administered insulin in the dining room which affected Resident #12 and #24. The facility census was 29. Review of facility policy, promoting/maintaining resident dignity, updated 1/1/24, showed: -It is the practice of the facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each…

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

Based on interviews and record review, the facility failed to act promptly and resolve resident grievances voiced during the resident council meetings and did not demonstrate a response and rationale for such response. The facility did not maintain documentation of resident concerns, attempts to resolve concerns or follow up actions. The facility census was 29. Review of facility policy, Resident Rights, dated 1/1/24, showed: -Be supported by the facility in exercising his or her rights; -Exercise his or her rights without interference, coercion, discrimination or reprisal from the facility; -To voice grievances to facility, or other agency that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal; -Have the facility respond to his or her grievances; Review of the grievance policy, updated 1/1/24, showed: -Prompt efforts to resolve include facility acknowledgement of a complaint/grievance and actively working toward resolution of that complaint/grievance; -Grievances may be voiced in following forums: -Verbal complaint during 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 interviews the facility staff failed to ensure residents had access to their personal funds after business hours and on the weekend. The facility census was 29. The facility did not provide policy on funds access. Review of facility policy, Resident Rights, revised December 2016 showed: -Manage his or her personal funds, or have the facility manage his or her funds; During a group interview four of four residents said they did not have access to funds on weekends or after hours. During an interview on 5/29/24 at 10:06 A.M., Business Office Manager (BOM) said: -Residents have access to money as long as someone is in the office; -There is no access to money on weekends. During an interview on 5/30/24 at 3:03 P.M., Administrator said: -Residents do not currently have access to funds on weekends or after business hours; -Residents should have access to money after business hours. During an interview on 5/30/24 at 3:03 P.M., Corporate Administrator said: -Residents did not have access to their personal funds after hours; -When residents want funds they make an effort to notify…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to establish and maintain a system that assured a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf when monthly personal funds reconciliation showed a negative balance and when the facility failed to reimburse residents' and/or their responsible parties after the residents were discharged which affected four of 12 residents (Resident #135, #136, #132, and #131). The facilities census was 29. 1. Review of facility monthly petty reconciliation logs showed: -[DATE] had negative petty cash ending balance of -302.23; -[DATE] had a negative petty cash ending balance of -61.88. Review of Interim Aged Analysis Summary, dated [DATE], showed: -Resident #135 (discharged [DATE]), had a negative balance of -1,190.66 in facility's operating account; -Resident #136 (discharged [DATE]), had a negative balance of -10.00 in facility'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.

Based on observation, record review and interviews, the facility failed to ensure they informed residents of their rights periodically during residents' stay both orally and in writing. The facility census 29. Review of resident right's policy, revised December 2016, showed: -Be informed of his or her rights as a resident of the facility and as a resident or citizen of the United States; - The policy listed out all of the residents' rights; - The policy did not specifically indicate when these rights should be communicated with the residents. During a group interview on 5/28/24 at 10:54 A.M. four of four residents had not received education about their resident rights. Review of resident council meeting minutes showed: -3/6/24, no documentation that resident rights were reviewed; -4/9/24, no documentation that resident rights were reviewed; -5/2/24, no documentation that resident rights were reviewed. During an interview on 5/30/24 at 10:05 P.M., Activity Director said: -He/She facilitated resident council meetings; -He/She had not gone over resident rights during resident council…

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 interviews and record review, the facility failed to clarify the status of the advanced directives (a legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions because of a serious illness or injury) for one of 12 sampled residents, (Resident #16). The facility census was 29. Review of the facility's policy for advance directives, revised December 2016, showed, in part: - Advance directives will be respected in accordance with state law and facility policy; - Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he/she chooses to do so; - If the resident is incapacitated and unable to receive information about his/her right to formulate an advance directive, the information may be provided to the resident's legal representative; - If the resident becomes able to receive and understand this information…

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 interviews and record review, the facility failed to provide Skilled Nursing Facility (SNF) Advance Beneficiary Notices (ABN) (the form Centers for Medicare and Medicaid (CMS) - 10055 to each resident. The SNF ABN provides information to residents/beneficiaries so they can decide if they wish to continue receiving the skilled services that may not be paid by Medicare and assume financial responsibilities. The facility used the incorrect form for three of 12 sampled residents, (Resident #27, #28 and #83). The facility census was 29. Review of the facility's policy for advance beneficiary notices, reviewed [DATE], showed, in part: - It is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage; - The Business Office Manager (BOM) is the contact person for the information regarding Medicare eligibility, coverage, and applying for benefits. A notice alerting residents/representatives of this contact person shall be posted conspicuously in the facility; - The current…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews, the facility failed to maintain a clean, comfortable, and homelike environment when the facility failed to maintain comfortable temperatures through out the facility, clean floors, replace chipped and broken tiles, replace hand sanitizer dispensers in resident rooms, replace broken or missing blinds, sand and paint drywall patches, repair scraped and missing paint from walls, and did not clean dust and cobwebs in facility. This affected all residents in the facility. The facility census was 29. Review of facility policy, Safe and Homelike Environment, reviewed 1/1/24, showed: -In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the residents to use his or her personal belongings to the extent possible. -Comfortable and safe temperature levels means that the ambient temperature should be relatively narrow range that minimizes residents' susceptibility to loss of body heat and risk of…

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

Based on observations, interviews, and record review, the facility failed to assure residents have the right to file grievances in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievances, the right to obtain a written decision regarding his or her grievance. This had the ability to affect all residents. The facility census was 29 Review of facility policy, Resident and Family Grievances, reviewed 1/1/24, showed: -Grievances may be voiced in following forums: -Verbal complaint to a staff member or grievance official; -Written complaint to a staff member or grievance official; -Written complaint to an outside party; -Information on how to file a grievance or complaint will be available to the resident. Information may include but is not limited to: a. Contact information of the grievance official with who a grievance can be filed, including…

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 staff failed to implement their Abuse and Neglect policy when they failed to complete employee background checks prior to staff working with residents, failed to complete employee disqualification list (EDL) checks, and failed to check the Certified Nurses' Assistant (CNA) Registry for all staff to ensure they did not have a Federal Indicator (a marker given by the federal government to individuals who have committed abuse/neglect). This affected eight of ten sampled staff (Licensed Pratical Nurse (LPN) C, Housekeeping Aide (HA) B, Nurse Aide (NA) A, Certified Nurse Assistant (CNA) F, HA A, Registered Nurse (RN) A, Dietary Aide C, and CNA B). The facility census was 29. Review of facility Policy, Abuse and Neglect, reviewed 1/31/24, showed: -It was the policty of the facility top provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. -Potential employees…

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 accurate comprehensive assessments were completed accurately on the minimum data set (MDS) for two of 12 sampled residents (Resident #3 and #14 ) when no preferences for customary routine and activities was obtained through resident, family, or staff interviews. The facility census was 29. Facility did not provide a policy on comprehensive assessments. Review of facility policy, activities, updated 4/1/24, showed: -Each resident's interest and needs will be assessed on a routine basis. The assessment shall include, but is not limited to: a. Resident Assessment Instrument (RAI) Process: MDS/Care Area Assessment (CAA)/Care Plan; b. Activity assessment to include resident's interest, preferences, and needed adaptations; c. Social history. Review of facility policy, care plans comprehensive person-centered, updated 1/1/24, showed: -The care plan interventions are derived from a thorough analysis of the information gathered as part of…

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

Based on interview and record review, the facility failed to ensure staff completed a Level 1 (indicated for any individual who may have an intellectual disability (ID), developmental disability (DD), or mental illness (MI) PASARR (Pre-admission Screening for Mental Illness/Mental Retardation or related condition) prior to admission to the facility. This affected two of 12 sampled residents, (Resident #14 and #26). The facility census was 29. Review of the facility's policy for resident assessment -coordination with PASARR program, dated 2023, showed, in part: - This facility coordinates assessments with the pre-admission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs; - All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening; - PASARR Level 1- initial…

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 they developed and implemented a comprehensive person - centered plan of care which included measurable objectives and timeframes to meet each resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment for four of 12 sampled residents, (Resident #25, #29 and #81). The facility census was 29. Review of the facility's policy for comprehensive person - centered care plans, revised December 2016, showed, in part: - A comprehensive, person - centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; - The Interdisciplinary Team (IDT) in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person - centered care plan for each resident; - The care plan interventions are derived from a thorough analysis 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 observations, interviews and record review, the facility failed to ensure staff followed professional standards when staff failed to obtain a order to check blood sugars for two of 12 sampled residents, (Resident #12 and #24), failed to ensure the low air loss mattress (medical mattress designed to prevent and treat pressure ulcers (PU, an area of localized damage to skin and underlying tissue caused by pressure, shear, friction and/or a combination of these) settings were correct for Resident #16. and additionally failed to obtain a physician's order for a side rail ( assistive device used to assist resident to reposition in bed) for Resident #29. The staff failed to ensure documentation was completed for medications and treatments for Resident #24. The facility census was 29. Review of the facility's policy for medication and treatment orders, revised July 2016, showed, in part: - Orders for medications and treatments will be consistent with principles of safe and effective order writing; -…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADL's) received the necessary services to maintain good personal hygiene when staff did not provide appropriate perineal care which affected one of 12 sampled residents (Resident #16) failed to provide oral care to two of the 12 sampled residents (Resident #12 and #16), failed to wash the face and hands of one of the 12 sampled residents (Resident #12), and failed to ensure staff provided shaving care to one of the 12 sampled residents (Resident #24). This affected three of the 12 sampled residents. The facility census was 29. Review of facility policy, ADL's, reviewed 1/1/24, showed: -Facility will, based on the resident's comprehensive assessment and consistent with resident's needs and choices, ensure a resident's abilities in ADL's do not deteriorate unless deterioration is unavoidable. -Care and services will be provided for the following activities…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide an ongoing program of meaningful activities on a daily basis to meet the interests and the physical, mental, and psychosocial well-being of each resident for five of 12 sampled residents (Residents #3, #14, #22, #24, and #25). The facility census was 29. Review of facility policy, activities, updated 4/1/24, showed: -It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, psychosocial well-being. Activities will encourage both independence and interaction within the community. -Activities will be designed with the intent to: a. Enhance the resident's sense of well-being, belonging, and usefulness. b. Create opportunities for each resident to have…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure staff used proper techniques to reduce the possibility of accidents or injuries when staff failed to lock residents' wheelchairs during transfers which affected three of 12 sampled residents, (Resident #3, #16 and #24). The facility census was 29. Review of invacare hydraulic 9805 portable patient lift and sling manual, revised 5/23/06, showed: -Wheelchair wheels locks must be in a locked position when lifting the person. Review of the facility's policy for using a mechanical lifting machine, revises July 2017, showed, in part: - The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device; - The policy did not address if the wheelchairs should be locked during the transfer. 1. Review of Resident #16's care plan, revised 9/28/23 showed: - The resident was dependent on staff for all ADLs; - The resident is totally dependent on the assistance of two staff for transfers with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to assure staff provide proper respiratory care when staff failed to ensure the oxygen concentrator had humidified sterile water, which affected one of 12 sampled residents, (Resident #16), failed to date the oxygen tubing for Resident #12 and Resident #81. The facility census was 29. Review of the facility's policy for oxygen administration, reviewed 1/1/24 showed: - Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person - centered acre plans, and the resident's goals and preferences; - Oxygen is administered under orders of a physician; - Change oxygen tubing and cannula weekly and as needed if it becomes soiled or contaminated; - Change humidifier bottle when empty, every 72 hours or per facility policy. Use only sterile water for humidification; - Keep delivery devices covered in plastic bag when not in use. 1. Review of Resident #16's care plan, revised 11/20/23…

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 residents for risk of entrapment from bed rails prior to installation when they failed to complete a side rail assessment (Resident #29), failed assess for an alternative to side rails (Resident #14 and #29), failed to obtain a physician's order (Resident #29) failed to measure entrapment zones for installed side rails (Resident #29) for two of 12 sampled residents (Resident #14, and #29). The facility census was 29. Review of facility policy, bed safety, dated 1/1/24, showed: -To prevent deaths/injuries from the beds and related equipment the facility shall promote the following approaches: a. Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; b. Review that gaps within the bed system are within the dimensions established; c. Ensure that when the bed system components are worn and need to be replaced,…

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

Based on interviews and record review, the facility failed to ensure they employed a Registered Nurse (RN) for eight consecutive hours per day, seven days per week. The facility census was 29. Review of the facility's policy for nursing services - Registered Nurse (RN), reviewed 1/1/24 showed, in part: - It is the intent of the facility to comply with Registered Nurse staffing requirements; - The facility will utilize the services of a Registered Nurse for at least eight consecutive hours per day, seven days per week. Review of the staffing sheets for October 2023 showed: - No RN scheduled for eight consecutive hours 10/27, 10/28. and 10/29. Review of the staffing sheets for March 2024 showed: - No RN scheduled for eight consecutive hours 3/10 and 3/11. Review of the staffing sheets for April 2024 showed: - No RN scheduled for eight consecutive hours 4/27 and 4/28. Review of the staffing sheets for May 2024 showed: - No RN scheduled for eight consecutive hours 5/4, 5/5, 5/11, 5/12, 5/18, 5/19, and 5/26. During an interview on 5/30/24 at 3:03 P.M., the Administrator and the Director…

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

Based on observations, interviews, and record review, the facility failed to ensure staff administered medications with a medication error rate of less than 5%. Facility staff made eight medication errors out of 25 opportunities for error, resulting in a medication error rate of 32%. This affected four of 12 sampled residents, (Resident #12, #16, #21, and #24). The facility census was 29. Review of the facility's policy for administering medications, revised April 2019, showed, in part: - Medications are administered in a safe and timely manner, and as prescribed. Review of the facility's policy for nasal spray administration, updated 4/15/24, showed, in part: - Nasal spray medications are administered by qualified staff as ordered by the physician and in accordance with professional standards of practice; - Verify orders and labeling prior to administration; - Compare the label with the order to verify correct medication, dose, route, and time of administration; - Agitate the contents in accordance with the manufacturer's instructions; - Occlude opposite nostril with your finger,…

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

Based on observations, interviews, and record review, the facility failed to ensure staff provided a safe and effective medication administration system that was free of significant medication errors when staff failed to prime insulin pens prior to administering insulin which affected two of 12 sampled residents, (Resident #12 and Resident #24). The facility census was 29. Review of the facility's policy for insulin pen, updated 1/1/24, showed, in part: - It is the policy of the facility to use insulin pens in order to improve the accuracy of insulin dosing, provide increased resident comfort, and serve as a teaching aid to prepare residents for self-administration of insulin therapy upon discharge; - Insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir; - Remove the pen cap from the insulin pen; - Wipe the rubber seal with an alcohol pad; - Screw the pen needle onto the insulin pen; - Dial two units by turning the dose selector clockwise; - With the needle pointing up, push the plunger, and watch to see that at least one drop of insulin…

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 medications had a pharmacy label on them to indicate who they belonged to for one of 12 sampled residents, (Resident #11), failed to ensure staff did not leave medication at bedside which affected Resident #16 and #24. Additionally, the staff failed to ensure the drawers of the medication cart were clean without any debris. The facility census was 29. Review of the facility's policy for storage of medications, revised November 2020 showed, in part: - The facility stores al drugs and biologicals in a safe, secure and orderly manner; - The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner; - Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. 1. Observation and interview on 5/28/24 at 3:38 P.M., showed the following in the South medication cart: - Resident #11 had a…

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

Based on observations, interviews, and record reviews, the facility failed to ensure the Dietary Manager (DM) had the appropriate competencies and skills sets to carry out the functions of the food and nutrition service. The facility census was 29. 1. Review of the facility job description for DM, dated 2020, showed: - Minimum requirements include one of the following: -Certification as a dietary manager. -Certification as a food service manager. -Has similar national certification for food service management and safety from a national certifying body. -Has an associate's or higher degree in food service management or in hospitality, if the course of study includes food service or restaurant management, for an accredited institution of higher learning. -Must also meet state requirements for food service managers or dietary managers. -Two years experience in food service management. Prior experience in healthcare foodservice preferred. Record review showed DM had enrolled in a course on 8/7/2023, and was not scheduled to complete the course until 11/14/24 November 14, 2024. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview the facility failed to establish and maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections when the failed to ensure all employees completed a Mantoux test screening for tuberculosis (TB) screening prior to hire. Review of six of 10 sampled employees (Nurse Aide (NA) A, Certified Nurse Aide (CNA) E, CNA F, NA B, Registered Nurse (RN) A, and CNA B) showed the facility was not in compliance. The facility also failed to provide alcohol-based hand rub (ABHR) on the memory care unit when hand sanitizer dispensers were left empty. The facility census was 29. 1. Review of facility policy, Infection Prevention and Control Manual Employee Health, dated 2019, showed: -All healthcare workers be tested for tuberculosis upon hire and yearly thereafter; -Initial testing will be two-step procedure with the first dose given before…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure the call light system was accessible for residents in their rooms when call lights were out of reach for two of twelve sampled resident(Resident #24 and #2), draped over the top of the over the bed light fixtures for two of twelve sampled residents (Resident #29 and #6) and when call lights had no strings attached to the wall units for two (Resident #14 and #21) of twelve sampled residents. The facility census was 29. Review of facility policy, call lights accessibility and timely response, updated [DATE], showed: -Purpose of the facility policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, adn bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. -Each resident will be evaluated ofr unique needs and preference to determine any special accommodations that may be…

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

Based on interviews and record review, the facility failed to complete a discharge summary for one of 12 sampled residents, (Resident #30). The facility census was 29. Review of the facility's policy for discharge summary and plan, revised December 2016, showed, in part: - When a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment; - The discharge summary will include a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident. The discharge summary shall include: current diagnosis medical history (including any history of mental disorders and intellectual disabilities); course of illness, treatment and/or therapy since entering the facility; current laboratory, radiology, consultation, and diagnostic test results; physical and mental functional status; Ability to perform activities of…

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

Based on observation, interview and record review, the facility failed to employ a qualified activity professional to oversee the activity program for the facility. The facility employees a full time activity director but he/she has not completed an approved activity professional training program. The facility census was 29. The facility did not provide a policy regarding activity professional training and requirements. Review of resident right's policy, dated 1/1/24, showed: -Resident's right to a dignified existence; -Be treated with respect, kindness, and dignity; -Self-determination; -Equal access to quality care. During an interview on 5/29/24 at 6:21 A.M., Activity Director said: -He/She had been the Activity Director since 2017; -He/She had one day of training before becoming activity director; -He/She had attended some training's with administrator, director of nursing, and social services provided by the coalition but no activity specific training certifications; -He/She had no specific dementia activity training. During an interview on 5/30/24 at 3:03 P.M., Corporate…

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 a resident with pressure ulcers received treatment as ordered for one resident (Resident #24) when staff did not float (prevent the resident's heels from resting on the mattress) heels in bed by using pressure off-loading boots, when they did not complete weekly skin assessments, and when they did not visualize the resident's wound dressing on two dates to ensure the dressing was in place. The facility census was 29. The facility did not provide a policy on pressure ulcers. Review of facility policy, Medication and Treatment orders, updated 1/1/24, showed: -Orders for medications and treatments will be consistent with principles of safe and effective order writing; -Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. 1. Review of Resident #24's quarterly MDS, dated [DATE], showed: -He/She had severe cognitive impairment; -He/She 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 observations, interviews and record review, the facility failed to ensure staff provided catheter care (sterile tube inserted into the bladder to drain urine) care in a manner to prevent a urinary tract infection (UTI, an infection in any part of the urinary system) or the possibility of a UTI when staff failed to clean the catheter tubing, the drainage spout and placed the graduate (a clear plastic container with markings used to collect and measure fluids) directly on the floor which affected one of 12 sampled residents, (Resident #16). The facility census was 29. Review of the facility's policy for urinary catheter care, revised September 2014, showed: - The purpose of this procedure is to prevent catheter - associated urinary tract infections; - Ensure that the catheter remains secures with a leg strap to reduce friction and movement at the insertion site. The catheter tubing should be strapped to the resident's inner thigh; - Use one area of the wash cloth for each downward, cleansing stroke; - Change the position of the wash cloth with each downward stroke; - Next,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility staff failed to report allegations of resident to resident sexual abuse to the Department of Health and Senior Services (DHSS) in the required time frame for three residents (Residents #1, #2, and #3). The facility census was 29. Review of the facility's Abuse and Neglect Policy, dated 2/21/17, included: - Any and all types of allegations will be investigated. - The Administrator and the Director of Nursing (DON) will be responsible for conducting, investigating and reporting the results to the proper authorities. The Administrator or DON will ensure allegations are investigated by conducting staff and resident interviews, conducting and completing assessments, making observations, and reporting allegations to the Missouri Department of Health and Senior Services. 1. Review of Resident #1's Annual Minimum Data Set (MDS, a federally mandated assessment completed by facility staff), dated 11/8/23, showed staff assessed the resident as: - Moderate…

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 facility policy and thoroughly investigate allegations of resident to resident sexual abuse for three residents (Residents #1, #2, and #3). The facility census was 29. Review of the facility's Abuse and Neglect Policy, dated 2/21/17, included: -The facility staff will help identify risk factors for abuse in the facility, for residents with unmanaged problematic behaviors, and staff training that is lacking in knowledge of management in behaviors. -The facility management team will institute measures to address the needs of residents to minimize the possibility of resident abuse. -Any and all types of allegations will be investigated. The Administrator and the Director of Nursing (DON) will be responsible for conducting, investigating and reporting the results to the proper authorities. The Administrator or DON will ensure allegations are investigated by conducting staff and resident interviews, conducting, and completing assessments, making…

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

Based on observation, interviews, and record review, the facility failed to ensure staff stored food in a sanitary manner and failed to maintain the kitchen in a sanitary manner. This had the potential to affect all residents residing in the facility. The facility census was 39. The facility did not provide a policy addressing kitchen sanitation or storage of toxic materials. Review of the manufacturer's instructions for the Low Temp Sanitizer Solution, dated 3/16/16, showed: - Directions for use: o Use a chlorine test kit and increase dosage as necessary to obtain the desired level of available chlorine; o Solutions containing an initial concentration of 100 parts per million (ppm) available chlorine must be tested and adjusted to insure that the available chlorine does not drop below 50 ppm. Review of the manufacturer's instructions for the sanitizer test strips, dated 8/5/22, showed: - Dip the strip into the sanitizing solution for 10 seconds; - Instantly compare the resulting color with color chart on label; - Chart on label showed: o 100 ppm - olive green, 200 ppm - aqua green,…

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

Based on record review and interviews, the facility failed to ensure they maintained a surety bond in an amount to cover any loss of theft to residents' money held in the facility's Resident Trust Fund (RTF) account which affected all residents who had money held in their RTF account. The facility census was 39. Review of facility policy Resident Funds/Trust - Surety Bond, not dated, showed: -It is the policy of facility to ensure that the facility maintains a surety bond for the safety of resident trust. -A surety bond is to be 1.5% of the total of the current balance. -If the required surety bond total is larger than the current bond it must be increased. -The facility insurance agent will be contacted to increase the surety bond. Review of the facility's surety bond letter, approved on 08/28/20, showed a amount of $40,000. Review of the RTF worksheet, completed on 10/05/2022, showed: -The average monthly balance for the facility's interest bearing account of $29,755.83; -The approved bond amount for this average monthly balance (Grand Total rounded to the nearest thousand x 1.5 =…

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, record review, and interviews, the facility failed to ensure staff prepared foods in a form designed to meet the needs of individual residents when they did not ensure the puree (a texture-modified diet in which all foods have a soft, pudding-like consistency) food had a smooth and appropriate consistency. This affected three residents identified by the facility as having orders for a pureed diet (Residents #8, #9, and #37). The facility census was 39. Review of the facility's Therapeutic Diets Policy, revised October 2017, showed: - Diet will be determined in accordance with the resident's informed choices, preferences, treatment goals and wishes; - A therapeutic diet is considered a part of treatment for a clinical condition, to modify nutrition or to alter the texture of the a diet for example: Altered consistency diet. Review of the facility's Puree Food Preparation Policy, revised November 2017, showed: - Pureed Diet: o Puree foods should be prepared in such a manner to prevent lumps or chunks; o The goal is a smooth, soft homogenous consistency similar…

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.