Bluffs, The

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to review and revise the plan of care with changes in the residents' needs for six residents (Resident #7, #8, #19, #61, #78 and #103) out of 27 sampled residents. The facility census was 115.1. Review showed the facility failed to provide a policy that directs staff when to review or revise care plans. 2. Review of Resident #7's Significant Change Minimum Data Set (MDS), a federally mandated assessment tool, dated 01/12/26, showed staff assessed the resident as:-Moderate cognitive impairment;-One or more unhealed pressure ulcers;-Two unstageable pressure ulcers. Review of the resident's progress notes, dated 12/02/25, showed staff documented the resident seen by wound clinic for two unstageable pressure ulcers to bilateral heals.Review of the resident's care plan, revised 1/20/26, showed it did not contain documentation in regard to the resident's bilateral heal unstageable pressure ulcers.During an interview on 01/30/26 at 12:18 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, facility staff failed to ensure medications were stored in a safe and effective manner when staff failed to discard expired medications/supplies for two out of five medication carts, and one of three medication storage rooms. The facility census was 115.1. Review of the facility's Storage and Labeling of Drugs Policy, dated 12/02/13, showed nursing staff shall check all stock medications routinely (no less than monthly) for expired medications the need for restocking and that the stock be rotated. Central supply staff or Director of Nursing (DON) Designee is responsible for checking expiration dates of all stock medication at least monthly. As new stock medications are brought in, stock is rotated to ensure oldestsamples are at the front. Expired medications are to be destroyed through use of drug buster. When a multi-dose medication vial is opened, the date opened is written on the vial or box. The vial is disposed within 30 days after it is opened. 2. Observation on 01/27/26 at 2:02 P.M., showed the Cherry hall medication cart…

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, facility staff failed to ensure the residents' environment remained free of accident hazards when staff failed to properly store medications in the memory care unit bathroom and left medications in one resident's bathroom (Resident #62). The facility census was 115.1.Review showed the facility failed to provide a policy to direct staff on medication storage safety. 2. Observation on 01/29/26 at 8:35 A.M., showed the whirlpool bathroom on the memory care unit unlocked, with the door propped open, and the following sitting out:-Nystatin (Antifungal) topical 100,000 unit/gram powder labeled with a resident's name;-Triad hydrophilic wound dressing pansement hydrophilic (a sterile, zinc-oxide based paste designed to manage light-to-moderate wound exudate by creating a moist, healing environment);-Calmoseptine ointment (a multipurpose, over-the-counter moisture barrier designed to treat skin irritations, diaper rash, incontinence, and minor wounds);-A&D ointment.3.…

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 provide a clean, homelike and comfortable environment when staff failed to maintain resident rooms in clean and good repair. The facility census was 117. 1. Review of the facility's Work Order Policy, dated 01/10/24, showed when staff noticed maintenance or repair needs, they should report this to their immediate supervisor, the charge nurse, or a member of the leadership team. 2. Observation on 10/28/24 at 11:40 A.M., showed resident occupied room [ROOM NUMBER]'s bathroom floor with a ripped area at the shower stall. Stained floor trim that was pulled away from the wall by the shower.i Observation on 10/28/24 at 2:31 P.M., showed resident occupied room [ROOM NUMBER]'s wall behind the bed with multiple areas of gouged and chipped paint. Observation on 10/29/24 at 10:20 A.M., showed resident occupied room [ROOM NUMBER]'s wall with scuff marks next to the bed and behind the recliner. Observation on 10/29/24 at 10:25 A.M., showed…

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, facility staff failed to provide written notice to residents or the resident's representatives regarding resident transfers to the hospital for four of four sampled residents (Resident #19, #48, #69, and #115). The facility census was 117. 1. Review of the facility's policies showed staff did not provide a policy for transfers to the hospital. 2. Review of Resident #19's medical record showed the following: -Transferred to the hospital on [DATE]; -Returned to the facility on [DATE]; -Transferred to the hospital on [DATE]; -Returned to the facility on [DATE]; -Staff did not document they notified the resident or resident representative of the transfer in writing. 3. Review of Resident #48's medical record showed the following: -Transferred to Emergency Department on 10/9/24 with return anticipated; -Staff did not document they notified the resident or resident representative of the transfer in writing. 4. Review of Resident #69's medical record showed the following:…

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, facility staff failed to provide written information to the resident and/or the resident's representative of their bed hold policy at the time of transfer to the hospital for two (Resident #19 and #69) of three sampled residents. The facility census was 117. 1. Review of the facility's policies showed staff did not provide a policy for transfers to the hospital. 2. Review of Resident #19's medical record showed staff documented the resident: -Transferred to the hospital on [DATE] and returned to the facility on [DATE]; -Transferred to the hospital on [DATE] and returned to the facility on [DATE]; -Staff did not document they notified the resident or the resident representative of the bed hold policy in writing. 3. Review of Resident #69's medical record showed staff documented the resident transferred to the hospital on [DATE] and returned to the facility on [DATE]. Staff did not document they notified the resident or the resident representative of the bed hold policy in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility staff failed to develop comprehensive care plans with resident-specific interventions to meet the resident's preferences and goals, and to address the resident's medical, physical, and psychosocial needs for five residents (Residents #45, #49, #56, #108, and #111) out of twelve sampled residents. The census was 117. 1. Review of the facility's policies showed the facility did not provide a policy for care plans. 2. Review of Resident #45's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 07/16/24, showed staff assessed the resident as: -Cognitively impaired; -Had inattentive and disorganized thinking that fluctuated; -No behaviors or wandering; -Diagnosis of dementia. Review of the resident's nurse notes, dated 08/28/24 through 10/28/24 showed staff documented: -On 08/28/24 at 2:38 P.M., intermittent behaviors; -On 09/16/24 at 12:41 P.M., resident began to get angry and yell at staff while taking resident to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, staff failed to document neurological checks after a fall for one (Resident #119) per facility policy, failed to document the removal of medication patches and the location of the new patch for one resident (Resident #48) who received Exelon Patches (to treat Alzheimer's disease) per facility policy and failed to document an indication for use on medications for seven (Resident #31, #45, #72, #87, #99, #111, and #324) of seven sampled residents. The facility census was 117. 1. Review of the facility's fall policy, dated October 2021, showed a fall is defined as an unintended change in position coming to rest on the ground or onto the succeeding lower surface and can occur while walking, standing, lying in bed and sitting. When a resident falls or is found on the floor, the licensed nurse will complete the appropriate fall documentation to include, fall observation and neurological checks on all residents who experienced unwitnessed falls or witnessed falls in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to transfer two residents (Residents #26 and #81) of three sampled residents by mechanical lift in a manner to prevent accidents. Facility staff failed to safely propel two residents (Resident #50 and #24) in a wheelchair and failed to properly secure medication in two treatment carts on the secured unit and the 500 hall. The facility census was 117. 1. Review of the facility's Use of Lift Machine policy, dated 12/06/19, showed: -Portable lift should be used by two nursing assistants to perform procedure; -Assist resident in guiding his/her legs; -Always keep the resident centered over the base and facing the caregiver operating the lift; -The policy did not contain direction for position of the base legs during the transfer. Review of Resident #26's 5-Day Minimum Data Set (MDS), a federally mandated assessment tool, dated 09/29/24, showed staff assessed the resident as: -Cognitively impaired; -Used a mechanical lift; -Impaired movement on…

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

Based on observation, interview, and record review, facility staff failed to properly maintain the temperature of hot food at or above 120 Degrees Fahrenheit (°F) for four residents (Resident #6, #49, #68, and #69) at the time of meal service and failed to implement a system to monitor food temperatures at the time of service. Failure to maintain foods at the proper temperature has the potential to affect all residents who received room trays. The facility census was 117. Review of the facility's policy Nutrition, dated 9/10/23, showed the facility strives to enhance the health and quality of likes of all residents through nutritious and appetizing meals. 1. Observation on 10/31/24 at 8:44 A.M., showed facility staff delivered a hall tray to Resident #6's room. The scrambled eggs were 82 °F and the oatmeal was 92 °F when checked with a calibrated stem-type thermometer by Department of Health and Senior Services (DHSS) staff. During an interview on 10/31/24 at 8:46 A.M., Resident #6 said the food is often cold, and especially breakfast. He/She said, I don't enjoy my food as much when…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to notify one resident (Resident #119) of one sampled resident's physician and representative in a timely manner when the resident had a fall with major injury. The facility census was 117. 1. Review of the facility's Notification of Family Members, Physician and Residents policy, dated 09/05/08, showed: -The purpose is to maintain communication and ensure that family members, physicians and residents are provided the opportunity to participate in the planning of medical care; -The resident's responsible party must be notified when there is a significant change of condition to include falls and injury; -The resident's physician and the facility administrator must be notified for significant changes of condition to include falls and injury; -The nurse on duty at the time the significant change occurs is responsible for making every attempt to contact the resident's family as soon as possible as well as the residents' physician if indicated and document…

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, facility staff failed to follow their Abuse & Neglect policy to investigate an allegation of misappropriation of property and failed to contact the local law enforcement within the required timeframe for one resident (Resident #1) out of one sampled residents. The facility census was 122. 1. Review of the facility's policy titled, Abuse and Neglect, revised 05/10/19, showed staff are directed to do the following: -All allegations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property will be thoroughly investigated. The facility will prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress; -All Alleged violations involving abuse, neglect, exploitation, or mistreatment of residents, including injuries of unknown source and misappropriation of resident property, shall be reported immediately to the administrator and the Missouri Department of Health and Senior Services (DHSS), twenty four hours from the time 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 interviews and record review, facility failed to report a missing electronic device for one resident (Resident #1) out of one sampled residents to the Department of Health and Senior Services (DHSS) within the required timeframe. This has the potential to affect all residents. The facility census was 122. 1. Review of the facility's policy titled, Abuse and Neglect, revised 05/10/19, showed staff are directed: -All Alleged violations involving abuse, neglect, exploitation, or mistreatment of residents, including injuries of unknown source and misappropriation of resident property, shall be reported immediately to the Administrator and the Missouri Department of Health and Senior Services (DHSS), but not later than two hours from the time the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury or twenty four hours from the time the allegation is made if the events that cause the allegation do not involve abuse and do not result in serious bodily…

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

Based on observation, interview and record review, facility staff failed to perform hand hygiene in a manner to prevent the spread of infection and failed to clean and sanitize soiled utensils between uses to prevent cross-contamination. Facility staff failed to maintain the kitchen floors and appliances in a clean manner to prevent the growth and harborage of bacteria. This had the potential to affect all residents. The facility census was 112. 1. Review showed the facility did not provide a policy for hand hygiene or glove changes. 2. Review of the facility's posting, Stop Germs! Wash You Hands, undated showed staff were directed to keep hands clean is one of the most important things we can do to stop the spread of germs and stay healthy. Observation on 04/25/24 at 12:00 P.M., showed dietary server C removed his/her gloves, applied clean gloves and did not wash his/her hands between glove changes. With the same gloves on, he/she touched a resident's sandwich, used a thermometer to test the food temperatures, and plated the lunch trays. During an interview on 04/25/24 at 1:13…

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, facility staff failed to complete a thourough investigation when staff reported one resident (Resident #5's) jar of quarters missing from his/her room. Staff did not interview additional residents, witnesses and family members. The facility census was 113. 1. Review of the facility's Abuse and Neglect policy, revised 5/10/19, showed the policy designed to prohibit and prevent abuse, neglect, exploitation, or mistreatment of residents, and misappropriation of resident property and to ensure appropriate intervention, investigation, and timely reporting in response to allegations of abuse, neglect, exploitation, or mistreatment of residents, including injuries of unknown source, and misappropriation of resident property, staff were directed as follows: -Investigation and Protection: All allegations of abuse, neglect, exploitation, or mistreatment of residents, including injuries of unknown source, and misappropriation of resident property will be thoroughly investigated. 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, facility staff failed to ensure the resident environment remained free of accident hazards when staff failed to secure medications and sharps on unattended medication carts. The facility census was 117. 1. Review of the facility's policy titled, Medication Administration, dated 9/09/23, showed staff must secure medications at all times. When not in use, medication cart drawers should be locked. Medications shall not be left unattended on counters or work stations. 2. Observation on 12/06/23 at 10:26 A.M., showed an unattended medication cart. The medication cart had a bottle of Escitalopram (antidepressant medication) 10 milligrams (mg) which contained 1 tablet, a bottle of Pantoprozale (used to reduce stomach acid) 40 mg which contained 3 tablets and a bubble pack of Omeprazole (used to reduce stomach acid) 20 mg which contained seven tablets on top of the cart. The medication cart sat unattended until 11:25 A.M., when Certified Medication Technician returned.…

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

Based on observation, interview and record review, facility staff failed to provide a safe and sanitary environment to help prevent the potential spread of COVID-19 (an acute respiratory illness in humans caused by the coronavirus, SARS-CoV-2) and other infections, when staff failed to follow acceptable infection control practices for COVID-19. Facility staff failed to wear an N95 (respirator) mask during the provision of care for two COVID-19 positive residents (Resident #3, and #4).The facility census was 117. 1. Review of the facility's policy, Guideline For Isolation Precautions, dated 9/28/21, showed the policy did not instruct what type of mask staff should use for suspected or confirmed SARS-CoV-2 infections. Review of the Centers for Disease Control (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 05/8/23, showed Health Care Providers (HCP) who enter the room of a patient with suspected or confirmed SARS-Co V-2 infection should adhere to Standard Precautions and use a…

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

Based on observation, record review, and interview, facility staff failed to provide a clean, safe, and comfortable homelike environment when staff failed to ensure one resident's (Resident #2) bed was in good repair. The facility census was 117. 1. Review of the facility's policy titled, Faulty Equipment, undated , showed staff shall alert their supervisor of faulty equipment. Supervisors should send an email to the Maintenance Department to report the issue. 2. Review of Resident #2's Significant Change Minimum Data Set (MDS), a federally mandated assessment tool, dated 09/30/23, showed staff assessed the resident as follows: -Moderate cognitive impairment; -Dependent on staff for bed mobility and transfers; -Diagnosis of dementia (progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), Anxiety Disorder, Schizophrenia (mental condition involving a breakdown in relation between thought, emotion and behaviors), Post-Traumatic Stress…

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, facility staff failed to report an allegation of employee to resident verbal abuse for one resident (Resident #1) to the Department of Health and Senior Services (DHSS) within the two hour required time frame. The facility census was 118. 1. Review of the facility's policy titled, Abuse and Neglect, revised May 2019, showed allegations of abuse, mistreatment, neglect, exploitation, and misappropriation of resident property will be appropriately investigated and timely reported per federal and state laws. Review showed all alleged violations involving abuse, neglect, exploitation, or mistreatment of residents, including injuries of unknown source and misappropriation of resident property, shall be reported immediately to the Administrator and the Missouri Department of Health and Senior Services, but not later than two hours from the time the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury, or 24 hours from the time the allegation is made if the events that cause the allegation do not…

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, facility staff failed to assist two residents (Resident #3 and #4) with their meals. The facility census was 117. 1. Review of the facility's policy, Activity of Daily Living (ADL) Services, dated 10/01/21, showed staff shall provide residents assistance with ADL's every shift, as appropriate. ADL's include bathing, grooming, dressing, eating, oral hygiene, ambulation and toilet activities. Review of the facility's Menu Board located on Walnut Grove Hall, showed lunch will be served between 12:20 P.M., and 12:30 P.M. 2. Review of Resident #3's Significant Change Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/15/23, showed staff assessed the resident as follows: -Severe cognitive impairment; -Supervision from staff member with eating; -Dependent on staff members for personal hygiene, dressing, bed mobility and sitting up in bed; -Diagnoses of Dementia (progressive or persistent loss of intellectual functioning, especially with impairment…

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

Based on observation, interview and record review, facility staff failed to maintain prepared foods at the proper temperature before service, failed to perform hand hygiene as often as necessary using approved techniques to prevent cross-contamination. Facility staff also failed to use the sanitizing solution according to facility policy and manufacturer's instructions and to allow clean and sanitized kitchenware to dry prior to use to prevent the growth of food-borne pathogens. Facility staff also failed to replace a missing ceiling tile in the food preparation area. The facility census was 111. 1. Review of the facility's policy titled, Food Temperatures policy, undated, showed hot foods on the tray line should be above 140 degrees F. If less than that, should be returned for reheating. The policy did not contain guidance specific to microwave reheating of meals. Review of the facility's policy titled, Infection Control - Nutritional Service, undated, showed: -Steam tables shall maintain hot foods at temperatures of 140 degrees Fahrenheit (F) or above; -All personnel shall observe…

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, facility staff failed to develop a comprehensive person-centered care plan for each resident to meet the resident's medical and nursing needs when staff failed to include in the plans oxygen use for two residents (Resident #3 and #55), Continuous Positive Airway Pressure (CPAP), a non-invasive ventilation machine that involves the administration of air usually through the nose by an external device at a predetermined level of pressure) use for two residents (Resident #48 and #417), and activity preferences for one resident (Resident #107). The facility census was 111. 1. Review of the policies provided by the facility showed no policy for Care Plans. Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual Version 3.0, dated October 2019, showed staff are directed to: -Regulations require facilities to complete, at a minimum and at regular intervals, a comprehensive, standardized assessment of each resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review facility staff failed to assist four out of six sampled dependent residents (Resident #39, #67, #80 and #93) with grooming and bathing as needed. The facility census was 111. Review of the policies provided by the facility showed no policy for the care of dependent residents. 1. Review of Resident #39's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 5/1/23, showed facility staff assessed the resident as: -Severe Cognitive impairment; -Totally dependent on one staff member for transfers; -Required extensive assistance from two or more staff members for dressing; -Totally dependent on one staff member for bathing. Review of the resident's care plan, dated 1/25/23, showed staff were directed to assist the resident to the extent needed to remain dry, clean, and well groomed. Review of the resident's Point of Care shower report, dated 4/1/23 through 6/28/23, showed the resident received a shower on 4/1/23, 4/26/23, 6/11/23, 6/13/23, 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 observation, interview, and record review, facility staff failed to transfer three residents (Residents #46, #29 and #39) by sling-type mechanical lift and one resident (Resident #78) by Sit to Stand mechanical lift), in a manner to prevent accidents. Additionally, staff failed to properly secure one medication cart. The facility census was 111. 1. Review of the facility's policy titled, Use of Lift Machine, dated 12/6/19, showed staff are directed to do the following: -Portable lift should be used by two staff members to perform procedure; -Make sure the lift is stable, legs fully extended, and locked. The lifter's base must be spread to the widest position and the brakes activated and locked. 2. Review of the Resident #46's Annual Minimum Data Set (MDS), a federally mandated assessment tool, 05/02/23, showed staff assessed the resident as: -Brief Interview of Mental Status (BIMS) score of 15 (cognitively intact); -Totally dependent on two staff members for transfers; -Diagnoses of Depression and…

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

Based on observation, interview, and record review facility staff failed to store and label medications in safe and effective manner in two of three medication storage rooms, and two of three medication storage carts. The facility census was 111. 1. Review of the facility's policy titled Storage/Labeling of Drugs, dated 12/2/2013, showed staff are directed to do the following: -All medications will be checked at least monthly for expiration dates; -Expired medications are to be destroyed through the use of drug buster. 2. Observation on 06/27/23 at 2:34 P.M., showed the Walnut hall medication storage room contained one box of Albulterol Sulfate 0.63 mg with an expiration date of May 2023. Observation on 06/27/23 at 3:00 P.M., showed the Cherry hall medication storage room contained one dressing change kit with an expiration date of May 2023. Observation on 06/27/23 at 3:15 P.M., showed the Walnut hall medication cart contained two loose white capsules, and two loose white oval tablets. Observation on 06/27/23 at 4:00 P.M., showed the Oak hall medication cart contained one loose…

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, facility staff failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment when staff failed to use hand hygiene during incontinence care for one resident (Resident #46) and wound care for one resident (Resident #42). Additionally, staff failed to decrease the risk of infection for four residents (Resident #55, #30, #3, and #79) when staff failed to ensure sanitary conditions for oxygen tubing, and failed to sanitize or clean a Continuous Positive Airway Pressure (CPAP), (a machine that used mild air pressure to keep breathing airways open while you sleep), machine and tubing for one resident (Resident #48). The facility census was 111. 1. Review of the facility's policy, Hand Hygiene, revised 10/30/2018, showed staff were directed to do the following: -When to wash hands (at a minimum): -When hands are visibly soiled (hand washing with soap and water); -Before and after direct resident contact…

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

Based on observation, interview and record review, facility staff failed to notify one resident's (Resident #64) physician when staff identified the resident with Moisture Associated Skin Damage (MASD) and failed to obtain treatment orders. The facility census was 111. 1. Review of the facility's policy titled Skin Care Protocol, dated 07/01/2011, showed staff are directed to do the following: -To ensure prompt and appropriate treatment for skin conditions identified by clinical staff, the following protocol may be initiated and the physician notified; -Initiate skin protocol; -Notify the physician of house protocol and obtain orders; -Update care plan, Treatment Administration Record (TAR), Physician Order Sheet (POS) with any new interventions for skin breakdown. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 05/18/2023, showed staff assessed the resident as: -Cognitively Intact; -Required extensive assistance from two staff members for bed mobility, transfers and toilet use; -Frequently incontinent of urine; -Occasional…

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

Based on observation, interview, and record review, facility staff failed to obtain a physician's order for the use of an indwelling catheter (a sterile tube inserted into the bladder to drain urine) for one resident (Resident #3), and failed to document when they discontinued or changed the catheter. Facility census was 111. 1. Review of the facility's policy titled, Catheter Care, revised October, 2018, showed staff were directed to document in the clinical notes the replacement of or any changes in apparatus, size of catheter, size of balloon, amount of fluid in the balloon when inflated and the date/time. Review of the facility's policy titled, Physician Visits and Medical Orders, undated, showed staff were directed to do the following: -Medical orders reflect changes in diagnosis, care, treatment, services, medical equipment needed and the resident's response to ordered care, services or treatment; -Members of the interdisciplinary team provide care, services and treatment according to the most recent medical orders and according to laws, regulations and standards of practice.…

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.