Quarters At Des Peres, The

Based on observation, interview and record review, the facility failed to store food in accordance with professional standards for food service safety by failing to date and cover food. In addition, the facility also failed to discard outdated food and failed to ensure kitchen equipment was kept clean during four of five days of observation. These deficient practices had the potential to affect all residents who consumed food from the facility's kitchen. The sample was 24. The census was 121. 1. Observation of the kitchen on 5/28/25 at 10:12 A.M., 5/29/25 at 3:45 P.M., 5/30/25 at 3:29 P.M., and 6/3/25 at 11:45 A.M., showed: -Dry storage room: -A container of dry grits, with a best by date of 8/12/24; -A package of tortillas opened and exposed to air; -Two boxes of angel food cake mixes, both with expiration dates of 2/14/24; -A box of lasagna pasta noodles opened and without a date; -Walk in freezer: -A bag of French toast tied in a knot at the end, without a date; -A bag of hamburger patties tied in a knot at the end, without a date; -An opened box of turkey sausage patties 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 maintain an infection prevention and control program when staff failed to change gloves, wash or sanitize hands and wear gowns during care for residents on enhanced barrier precautions (EBP, precautions for use during high-contact resident care activities for residents infected with a multidrug-resistant organism (MDRO, microorganisms that are resistant to one or more classes of antimicrobial agents) for four residents (Residents #105, #66, #47 and #1). In addition, the staff failed to disinfect the accucheck machine (used to test blood sugar) properly for one resident (Resident #47). Furthermore, staff placed unbagged dirty linens and briefs on the floor during care of two residents (Residents #105 and #66). Moreover, the facility failed to ensure newly hired employees completed the 2-step Mantoux tuberculin skin test (TST), used to test for latent tuberculosis (TB) infection, as required for 9 out of 10 employees residents sampled. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow acceptable nursing practice when staff left medication in one resident's room. (Resident #105). In addition, an inhaler was observed at the bedside table of a resident who did not have a physician order for self-administration or for medications to be left at the bedside. (Resident #62) . The sample was 24. The census was 121. Review of the facility's Self-Administration of Medications policy, dated 12/17, showed: -Policy: In order to maintain the residents' high level of independence, residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer. -For those residents who self-administer, the interdisciplinary team verifies the resident's ability to self-administer medications by means of a skill assessment conducted on a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure third party liability (TPL) forms were followed up on for the final accounting within 30 days for residents who expired. This affected two of two sampled residents who expired and had money in their resident trust account. (Residents #267 and #268). The census was 121. 1. Review of Resident #267's resident trust fund account, showed: -Resident expired on [DATE]; -A balance of $8297.87; -TPL completed and mailed [DATE]. 2. Review of Resident #268's resident trust fund account, showed: -Resident expired on [DATE]; -A balance of $2798.79; -TPL completed and undated time of mailing. 3. During an interview on [DATE] at 2:30 P.M., the Regional Business Office Manager and the Business Office Manager said they just sent the TPL letters for both residents on [DATE]. They were aware the letters were required to be sent within 30 days of a residents' death. The Business Office employee, who was responsible for sending out the letters, was terminated last…

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

Based on observation, interview and record review, the facility failed to provide care consistent with professional standards of practice when the facility failed to perform/document post-fall neurological assessment (an assessment that checks the resident's mental status, level of consciousness, pupil reaction, motor (movement) response to stimulation, and sensation) and complete post fall assessments per policy for one resident (Resident #105). The sample was 24. The census was 121. Review of the facility's Fall Management policy, date 2/28/23, showed: -An un-witnessed fall occurs when a resident is found on the floor and resident/employee is unaware how he/she got there; -Prior to moving the resident, the charge nurse will evaluate for injury; -Complete neurological evaluation post-fall on residents with potential head injury or unwitnessed fall; -Implement Post-Fall Evaluation/Documentation, all shift evaluation/documentation X72 Hours. -Potential Head Injury: charge nurse shall complete a neurological evaluation per instructions on resident's post-fall with potential head…

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

Based on observation, interview and record review the facility failed to provide care consistent with professional standards of practice, when staff failed to timely administer or document treatment orders and failed to document a description of the wounds on admission for one resident. (Resident #215). The sample was 24. The census was 121. Review of the facility's Wound Management Policy, dated 11/15/22, showed: Policy: To promote wound healing of various types of wounds, the facility will provide evidence-based treatments in accordance with current standards of practice and physician orders; -Charge nurse will notify physician in the absence of treatment orders; -Wound characteristics/documentation: -Location of the wound pressure injury & stage; -Size (Shape, Depth, Tunneling and/or Undermining). Volume & Exudate (drainage) characteristics; -Pain evaluation; -Presence of infection/bioburden. -Condition of the wound bed & wound edges. condition of the peri-wound (area around the wound); -Treatments will be documented on the Treatment Administration Record (TAR). Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow their policy for dialysis (a procedure that cleanses the blood of its impurities) when staff failed to obtain a physician order for dialysis and failed to document assessments for two residents (Residents #32 and #217) and failed to ensure the blood pressure was not obtained in the same arm as the dialysis access site (e.g. arteriovenous (AV, a surgically created connection between an artery and a vein, for dialysis shunt or graft (a synthetic tube used to create the connection)) for one resident (Resident #27). The facility identified 24 residents who received dialysis services, four residents were sampled, and issues were found with three. The sample was 24. The census was 121. Review of the facility's undated Hemodialysis policy, showed: -Policy: this facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and 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 interview and record review, the facility failed to implement their policy and procedure for the monthly drug regimen review by failing to ensure the physician or designee responded to the pharmacy recommendation timely for two of five residents sampled for medication review (Residents #35 and #62). The sample was 24. The facility census was 121. Review of the facility's Medication Regimen Review, revised 8/17, showed: -Policy: The pharmacist performs a comprehensive review of each resident's medical record at least monthly. The medication regimen review (MRR) is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. While conducting the MRR the pharmacist may also collaborate with members of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident was administered Triumeq (Abacavir-Dolutegravir-Lamivudine, a prescription medication used to treat human immunodeficiency virus (HIV, a virus that attacks the body's immune system)) as ordered (Resident #105). In addition, the facility failed to ensure the prescribing Infectious Disease (ID) physician was notified timely when the medication was not available. The facility failed to have a process in place to follow up timely on prior authorizations resulting in the resident missing multiple doses. The sample was 24. The census was 121. Review of the facility's Medication Administration - Prep and General Guidelines policy, dated 12/17, showed: -If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time (e.g., the resident is not in the facility at scheduled dose time, or a starter dose of antibiotic is needed), the space provided on the front of the Medication…

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 follow the puree recipes for four of the five purees foods observed. This deficient practice had the potential to effect two residents who consumed pureed meals. The sample was 24. The census was 121. 1. Observation on 6/2/25 at 10:15 A.M., showed [NAME] CC prepared pureed peas. He/She added an unmeasured amount of peas into the blender. He/She placed one slice of bread into the blender. He/She then poured an unmeasured amount of broth into the blender and pureed the items for approximately 15 seconds. He/She stopped the blender, removed the lid and placed another half slice of bread into the blender and blended the items for an additional 20 seconds. The puree was thin in consistency. [NAME] CC did not consult the recipe book during the preparation. Review of the pureed green peas recipe, showed the following for ten servings: -Prepare according to regular recipe; -Measure desired number of servings into food processor. Blend until smooth. Add water if product needs thinning. Add commercial thickener if…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY See Event ID 0WE513. Based on interview and record review, the facility failed to ensure staff followed the change of condition policy for one resident (Resident #50) when staff failed to ensure the resident's physician was aware of the resident's change of condition identified on 12/13/24. The resident was transported to the hospital for assessment and treatment when the physician was notified on 12/15/24 after the resident was found unresponsive and with slow shallow breaths. Four residents were sampled for change in condition. The census was 116. Review of the facility's Notification Of A Change In Condition policy, revised on 4/26/23, showed: -Policy: The Attending Physician/Physician Extender (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist) and the Resident Representative will be notified of a Change in a Resident's Condition, per Standards of Practice and Federal and/or State Regulations; -Responsibility: All Licensed Nursing Personnel, Nursing Administration, and Director 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 See Event ID 0WE513. Based on interview and record review, the facility failed to provide services that meet professional standards of clinical practice. On the day shift (7:00 A.M.-3:00 P.M.) of 12/15/24, on [NAME] Hall, the facility failed to ensure a Licensed Practical Nurse (LPN) or a Registered Nurse (RN) was available to administer medications and gastrostomy (g-tube) flushes, provide treatments, complete assessments, and/or monitoring of residents as ordered and the Director of Nursing (DON), who arrived at the facility between 3:00 P.M. and 4:00 P.M. on 12/15/24, falsely documented he/she administered medications and g-tube flushes, completed treatments and assessments and/or monitoring of residents from 7:00 A.M. through 3:00 P.M. Forty-one residents resided on [NAME] hall. Fifteen were sampled and problems were identified with all 15 (Residents #6, #14, #34, #43, #44, #50, #56, #57, #58, #59, #60, #61, #62, #6, and #64). In addition, LPN FF and/or Certified Medication Technician (CMT) GG obtained…

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 See Event ID 0WE513. This deficiency is uncorrected. For previous examples, refer to the Statement of Deficiencies dated 10/31/24. Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 32 opportunities observed, 10 errors occurred resulting in a 31.25% error rate (Residents #53, 54, 51, and 52). The census was 116. Review of the facility's Medication Administration - General Guidelines policy, dated 12/2017, showed: -Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling, and administration). The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. -Five Rights: Right…

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.

See Event ID 0WE512. Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 30 opportunities observed, eight errors occurred resulting in a 26.66% error rate (Residents #41 and #42). The census was 118.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide services that meet professional standards of clinical practice. On the day shift (7:00 A.M.-3:00 P.M.) of 12/15/24, on [NAME] Hall, the facility failed to ensure a Licensed Practical Nurse (LPN) or a Registered Nurse (RN) was available to administer medications and gastrostomy (g-tube) flushes, provide treatments, complete assessments, and/or monitoring of residents as ordered and the Director of Nursing (DON), who arrived at the facility between 3:00 P.M. and 4:00 P.M. on 12/15/24, falsely documented he/she administered medications and g-tube flushes, completed treatments and assessments and/or monitoring of residents from 7:00 A.M. through 3:00 P.M. Forty-one residents resided on [NAME] hall. Fifteen were sampled and problems were identified with all 15 (Residents #6, #14, #34, #43, #44, #50, #56, #57, #58, #59, #60, #61, #62, #6, and #64). In addition, LPN FF and/or Certified Medication Technician (CMT) GG obtained resident blood glucose…

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 medication error rate of less than 5%. Out of 30 opportunities observed, eight errors occurred resulting in a 26.66% error rate (Residents #41 and #42). The census was 118. Review of the facility's medication administration-Preparation and General Guidelines, revised August 2014, showed: -For residents able to swallow or who have difficulty swallowing tablets which can be appropriately crushed may be ground coarsely and mixed with appropriate vehicle (such as applesauce) so that the resident receives the entire dose ordered; Please consult with the product literature or Do Not Crush lists which the facility may have or with the pharmacist if there is a question about the medications to be crushed; -The need for crushing medications should be indicated on the resident's orders and the Administration Record (AR) so that all personnel administering medications are aware of this need and the consultant pharmacist can advise on safety…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure staff followed the change of condition policy for one resident (Resident #50) when staff failed to ensure the resident's physician was aware of the resident's change of condition identified on 12/13/24. The resident was transported to the hospital for assessment and treatment when the physician was notified on 12/15/24 after the resident was found unresponsive and with slow shallow breaths. Four residents were sampled for change in condition. The census was 116. Review of the facility's Notification Of A Change In Condition policy, revised on 4/26/23, showed: -Policy: The Attending Physician/Physician Extender (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist) and the Resident Representative will be notified of a Change in a Resident's Condition, per Standards of Practice and Federal and/or State Regulations; -Responsibility: All Licensed Nursing Personnel, Nursing Administration, and Director of Nursing; -Procedure: -1.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain air temperature at the preference of Resident #6 in his/her room and failed to maintain a properly functioning thermostat in the same resident's room. He/She complained about the cold room temperature. Per the resident, the cold temperature caused him/her to not get enough sleep. This had the potential to affect Resident #6 and Resident #19. The census was 129. Review of the facility's Maintenance Supervisor job description, revised 05/2022, showed: -Essential functions of Maintenance Supervisor: -Report to the Administrator regarding the physical and structural conditions of the center and the status of work in progress; -Perform all assigned tasks in a professional manner to reflect the highest integrity of the Maintenance Department; -Coordinate the repair of equipment or recommend the replacement of or additions to equipment or center as necessary; -Schedule and supervise maintenance repair work, alterations, remodeling, minor…

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

Based on interview and record review, the facility failed to follow their written policy when staff did not permit one resident (Resident #2) to return to the facility after he/she had been transported to the hospital. The census was 129. Review of the facility's Discharge Transfer Involuntary policy, last reviewed 10/7/21, showed: Policy: -Transfer and discharge include movement of a resident to a bed outside of the facility whether that bed is in the same physical plant or not. The facility must permit each resident to remain in the facility and not transfer or discharge the resident from the facility unless specific criteria, as outlined below, are met. Responsibility: -All staff monitored by the Director of Nursing (DON) and Administrator; Procedure: -A written or telephone order is required from the attending physician for the discharge of a resident, except in emergency situations; -The Interdisciplinary team and the resident's physician must document in the resident's record when a resident is transferred or discharged ; -If transferred to another health care facility upon…

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 Surveyor: [NAME], [NAME] Based on interview and record review, the facility failed to ensure residents had complete, accurate, and individualized care plans to address the specific needs of one of three sampled residents (Resident #10). The census was 129. Review of the facility's Comprehensive Person-Centered Care Plan Policy and Procedure, reviewed [DATE], showed: -Policy: Each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences and goals that identify how the interdisciplinary team will provide care; -Procedure: The comprehensive care plan shall be fully developed within 7 days after the completion of the admission Minimum Data Set (MDS). The interdisciplinary team, along with the resident and/or resident representative, will identify the resident problems, needs, strengths, life history, preferences, and goals. Review of Resident #10's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE],…

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 resident care plans were revised timely. One resident returned from the hospital with a diagnosis of aspiration pneumonia (a type of lung infection that is due to material from the stomach or mouth entering the lungs) and aspiration precautions to be used during meals which had not been added to the care plan (Resident #5). In addition, the facility failed to add fall interventions to another resident's care plan (Resident #13). The census was 129. Review of the facility Fall Management policy, last reviewed on 2/28/23, showed: -Policy: To provide an environment that remains as free of accident hazards as possible. The facility will complete a Morse Fall Scale Evaluation on residents to determine who are at risk for falling and to develop appropriate interventions to provide supervision and assistive devices to prevent to minimize further falls and/or to reduce injuries; -Responsibility: Nursing Personnel, Nursing Administration,…

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 followed aspiration precautions for one resident with a recent diagnosis of aspiration pneumonia (a type of lung infection that is due to material from the stomach or mouth entering the lungs) (Resident #5). In addition, the facility failed to ensure one resident with a history of falls, had a mat on the floor on both sides of his/her bed, and failed to ensure staff kept the resident's bed in the lowest possible position when the resident was in bed and unattended (Resident #13). The census was 129. Review of the facility Fall Management policy, last reviewed on 2/28/23, showed: -Policy: To provide an environment that remains as free of accident hazards as possible. The facility will complete a Morse Fall Scale Evaluation on residents to determine who are at risk for falling and to develop appropriate interventions to provide supervision and assistive devices to prevent to minimize further falls and/or to reduce injuries;…

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 Surveyor: [NAME], [NAME] Based on interview and record review, the facility failed to ensure residents were free from significant medication error after one resident (Resident #12) received two different blood thinner medications simultaneously. The sample size was three residents. The census was 129. Review of the facility's Physicians Orders Policy, reviewed 9/28/22, showed: -Policy: To provide guidance and ensure Physician Orders are transcribed and implemented in accordance with Professional Standards, State & Federal Guidelines; -Procedure: Physician orders will be transcribed to the appropriate administration record. Physician orders must be documented clearly in the medical record. Telephone/Verbal orders should be read back and verified with the prescriber. Review of Resident #12's admission Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 9/4/24, showed: -admission 9/4/24; -Able to make self understood; -Cognitively intact; -Diagnoses included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents receiving dialysis (a treatment for kidney failure that rids the body of unwanted toxins, waste products, and excess fluids by filtering your blood) received their diets as ordered (Residents #5 and #17). The facility identified 14 residents that received in-house dialysis. Two were sampled and problems were found with both. The census was 129. Review of the Dietary Aide job description, revised 5/2022, showed: -Essential Functions of Dietary Aide: Prepare food trays for general and therapeutic diets. Prepare special diet foods as necessary. Review of the Certified Nursing Assistant (CNA) job description, revised on 1/2024, showed: -Essential Functions of CNA: Provides for activities of daily living (ADL) by assisting with serving meals and feeding residents as necessary. 1. Review of Resident #5's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/14/24,…

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 maintain medical records that were complete and accurately documented, in accordance with accepted professional standards and practices, for one resident who had a change of condition on 8/6/24 and went to the hospital where he/she was admitted (Resident #2). The sample was 18. The census was 129. Review of the facility's Discharge Transfer - Involuntary Policy, last reviewed 10/7/21, showed: -Responsibility: All staff monitored by the Director of Nursing (DON) and Administrator; Procedure: -The Interdisciplinary team and the resident's physician must document in the resident record when a resident is transferred or discharged ; -Before a facility transfers a resident to a hospital or allows a resident to go on therapeutic leave, the nursing facility must provide written information to the resident and the resident's representative or legal representative that specifies the duration of the bed-hold policy and the facility's policies regarding bed-hold. Review of Resident #2's physician order sheet, showed: -Admit to…

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

See citation written at event ID # 8BCQ12. This deficiency is uncorrected. For previous examples, see the statement of deficiencies dated 1/17/24. Based on observation, interview and record review, the facility failed to promote and facilitate self-determination for residents who were dependent on staff for transfer assistance by failing to ensure residents were out of bed daily, in accordance with resident preferences. The facility also failed to provide showers/baths per resident preferences and failed to provide appropriate personal care items for residents. This affected three of 18 sampled residents (Resident #89, #36, and #71). The census was 107.

See citation written at event ID # 8BCQ12. Based on observation, interview and record review, the facility failed to provide a comfortable and homelike environment for residents when staff failed to ensure common areas and resident rooms were free from strong odors of urine that persisted throughout the survey process. The sample size was 18. The census was 107.

See citation written at event ID # 8BCQ12. This deficiency is uncorrected. For previous examples, see the statement of deficiencies dated 1/17/24. Based on observation, interview and record review, the facility failed to provide residents with the necessary services to maintain adequate personal hygiene for three residents observed with odors and dirty clothing (Resident #89, #36, and #71). The sample size was 18. The census was 107.

See citation written at event ID # 8BCQ12. Based on observation, interview and record review, the facility failed to uphold a resident's right to a dignified existence when staff left a bag of briefs soiled with bowel movement (BM) on the resident's nightstand, approximately one foot from the head of the resident's bed for an extended amount of time (Resident #89). The resident reported having a fear of retaliation from the facility. In addition, staff left a soiled towel on the floor of the resident's room and failed to remove a trash can smeared with BM from the resident's room. The sample size was 18. The census was 107.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to promote and facilitate self-determination for residents who were dependent on staff for transfer assistance by failing to ensure residents were out of bed daily, in accordance with resident preferences. The facility also failed to provide showers/baths per resident preferences and failed to provide appropriate personal care items for residents. This affected six of 32 sampled residents (Residents #58, #89, #60, #75, #42 and #56). The census was 107. Review of the Resident Rights Policy, dated 4/26/23, showed: -The facility shall treat residents with kindness, respect, and dignity and ensure resident rights are being followed. The resident/resident representative will be informed on their rights upon admission; -Procedure: Upon admission to the facility the resident and/or resident representative will be informed of the residents' [NAME] of Rights; -Resident/resident representative will sign the residents' [NAME] of Rights Acknowledgement;…

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 a comfortable and homelike environment for residents when staff failed to ensure common areas and resident rooms were free from strong odors of urine that persisted throughout the survey process. The sample size was 18. The census was 107. Review of the facility's undated Basic Cleaning Concepts policy, showed: -General Sanitizing: To make a surface or area clean by removing dirt, germs or unwanted substances; -Contamination: The presence of germs on hands or on a surface such as clothes, gowns, gloves, bedding, toys, surgical instruments, patient care equipment, dressing or other inanimate objects. Review of the facility's undated Hospital Clean policy, showed: -Hospital clean is a measure of cleanliness routinely maintained in care areas of the health care setting. Cleaning practices are periodically monitored and audited with feedback and education; -Waste is disposed of properly; -High touch surfaces in client/patient/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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized care plans to address specific needs of the residents for six of 32 sampled residents (Residents #49, #263, #12, #86, #75, and #9). The census was 107. Review of the facility's Comprehensive Person-Centered Care Plan Policy, dated 10/23/19, showed: -Policy: Each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care; -Responsibility: Interdisciplinary Team Members; -Definitions: -Interdisciplinary: All disciplines will collaborate and develop a plan of care that meets the resident's needs, preferences and goals; -Comprehensive Person-Centered Care Plan: Contains services provided, preference, ability and goals for admission, desired outcomes and care level guidance; -Procedure; -The comprehensive person-centered care plan shall be fully developed within…

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 residents with the necessary services to maintain adequate personal hygiene for four residents (Residents #265, #89, #12 and #68) observed with long and dirty fingernails, unkempt facial hair, and soiled clothing. The sample size was 32. The census was 107. Review of the facility's Activities of Daily Living (ADL) Care Bathing policy, last reviewed 7/21/22, showed: -Policy: Nursing staff will assist in bathing residents, to promote cleanliness and dignity. The charge nurse will be made aware of residents who refuse bathing. Review of the facility's ADL Care Shaving policy, last reviewed 7/21/22, showed: -Policy: The facility will provide aid with shaving as directed in the plan of care. ADL care will include shaving to promote cleanliness and preserve dignity. Review of the facility's Nail Care policy, last reviewed 7/21/22, showed: -Policy: The purpose of nail care is to clean the nail bed, trim nails, & prevent infection; -Key…

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 side rails were accurately assessed as a necessary device prior to installation and use. The facility also failed to document usage in the resident's care plan for four of 32 sampled residents (Resident #12, #86, #75 and #9). The census was 107. Review of the facility's Physical Restraint policy, dated 7/26/23, showed: -Policy: Physical restraints are not to be used to limit resident mobility for the convenience of staff and must comply with life safety requirements. If a resident's behavior is such that it may result in injury to the resident or others and any form of physical restraints is utilized, it should be in conjunction with treatment procedures designed to modify the behavioral problems for which the resident is restrained, or as a last resort, after failure of attempted therapy; -Definitions: -Physical Restraint: Any manual method, physical method, or mechanical device, material or equipment attached to or adjacent 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, the facility failed to ensure a medication error rate of less than five percent. Out of 37 opportunities, five errors occurred, resulting in a 13.51% error rate (Residents #60, #47, #28, and #266). The census was 107. Review of the facility's Medication Administration-Preparation and General Guidelines policy, dated revised August 2014, showed: -Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). - Right resident, right drug, right dose, right route and right time, are applied for each medication being administered. A triple check of these 5 rights is recommended at three steps in the process of preparation of a medication for administration: (I) when the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to store medication and medical equipment in accordance with professional principles, including abiding by the expiration date on wound and ostomy (surgery that creates an opening from an area inside the body to outside the body) care supplies. Concerns were found in two of five medication rooms and in one of five treatment carts in the facility. The sample size was 32. The facility census was 107. Review of the facility's Storage of Medications policy, dated 11/2018, showed the following, under the Expiration Dating (Beyond-use dating) section: -Expiration dates (Beyond-use dates) of dispensed medications shall be determined by the pharmacist at the time of dispensing; -The nurse will check the expiration date of each medication before dispensing it; -No expired medications will be administered to a resident; -All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. 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 and interview, the facility failed to provide and offer snacks at bed time. The census was 107. During a group interview on 1/10/24 at 1:43 P.M., seven residents, who the facility identified as alert and oriented, attended. All seven residents said the facility did not offer snacks anymore. They used to receive them but had not in several months. One resident said family members had to bring in snacks. Another resident said if they wanted snacks, they had to go to the vending machine. During an interview on 1/10/24 at 2:10 P.M., Resident #35 said residents have to wait a long time for meals. They are served breakfast between 8:00 and 9:00 A.M. and dinner is around 5:00 P.M. During an interview on 1/12/24 at 11:28 A.M., Certified Nursing Assistant (CNA) M said he/she worked at the facility for approximately a month and had not seen snacks given out to residents. Observation of the dry storage area in the main kitchen on 1/17/24 at 3:10 P.M., showed graham crackers, pudding, chips, crackers,…

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

Based on observation and interview, the facility failed to serve food under sanitary conditions when staff failed to store food in a safe and sanitary manner, failed to date food items and to discard outdated food, and failed to use utensils to the serve food. The census was 107. Review of the facility's Refrigeration Policy, dated 3/31/23, revised on 8/16/23, showed; -POLICY: Ensure food storage and safety practices are maintained and monitored and comply with Federal and State regulations governing food storage and safety; -RESPONSIBILITY: Dietary Aide, Dietary Cook, & Dietary Manager; -PROCEDURE: Foods shall be stored in an organized manner and shall be maintained in their original containers unless they are considered a leftover. All leftovers shall be labeled and dated with an expiration; -Refrigerators shall be checked daily by the Dietary Manager and/or his/her designee to ensure leftovers are discarded before expiration date and all food is properly stored; -Storage of food shall follow a FIFO (first in, first out) system. Stock labeled with date when received to include…

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

Based on observation, interview and record review, the facility failed to ensure staff completed routine inspections of bed frames, mattresses and bed/side rails as a part of a regular maintenance program to identify areas of possible entrapment for four (Residents #12, #86, #75 and #9) of 32 sampled residents. The census was 107. 1. Observation on 1/8/24 at 11:14 A.M., 1/9/24 at 7:48 A.M. and 9:18 A.M., 1/10/24 at 7:08 A.M., 1/11/24 at 4:05 A.M. and 1/12/24 at 8:28 A.M., showed the Resident #12 lay in bed on his/her back. Quarter length U-rails/side rails were raised on both sides. Review of the resident's medical record, showed no Maintenance Assessment for the use of side rails. 2. Review of Resident #86's admission Minimum Data Set, (MDS) a federally mandated assessment completed by facility staff, dated 11/30/23, showed: -Cognitively intact; -Exhibited no behaviors; -Required supervision or touching assistance for mobility; -Required supervision or touching assistance for transfers; -Diagnoses included stroke and asthma. Observation on 1/8/24 at 11:14 A.M., 1/9/24 at 7:48 A.M.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure code status was entered into the medical record for two of 32 sampled residents (Residents #263 and #89). The census was 107. Review of the facility's Advanced Directive Policy, dated last reviewed [DATE], showed: -Policy: It is the policy of the facility to respect the resident's right of self-directed care including the right to issue advance directives on health care, to refuse/accept treatment, to make informed decisions, and/or appoint a health care agent to make decisions on behalf of the resident when the resident lacks the capacity to do so. -Upon admission the facility will provide resident who is medically deemed competent or resident representative, who does not have an existing advance directive, with written information and instructions regarding the right to make advance directives prior to the initiation of care or at any requested time; -The resident may revise/revoke an advance directive at any time; -lf the resident is unable…

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 nursing services that met professional standards of quality to residents at the facility. Facility staff failed to document a missed imaging test appointment as well as subsequent follow up actions for one resident (Resident #56), and failed to document the administration of a blood-thinning agent for another resident (Resident #209). Additionally, the facility failed to identify one resident (Resident #265) had an intravenous (IV, a thin flexible tube inserted into a vein) in his/her right forearm and failed to obtain a physician order to discontinue the IV or obtain orders to maintain the IV. The resident sample was 32. The facility census was 107. Review of the facility's Medication Administration - General Guidelines policy, revised December, 2017, showed: -The policy is designed to ensure medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized…

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

Based on observation, interview and record review, the facility failed to ensure a resident who is fed by enteral means (also known as tube feeding, a way of sending nutrition right to the stomach or small intestine) safely received the appropriate treatment and services when the head of bed was not elevated during feeding. This affected one of 32 sampled residents (Resident #49). The census was 107. Review of the facility Policy & Procedure Tube Feeding: Continuous Tube Feeding Policy, dated February 2016, showed: -Purpose: To provide nourishment to the resident who is unable to obtain nourishment orally. -Verify physician order for feeding; -Gather necessary equipment for procedure; -Identify resident and explain procedure; -Always keep resident receiving continuous feedings in semi-Fowler's (position in which an individual lies on their back on a bed, with the head of the bed elevated between 30-45 degrees, and the legs of the patient can be either straight or bent at the knees ), or higher position. Review of Resident #49's annual Minimum Data Set (MDS), a federally mandated…

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 obtain stop dates of 14 days or less on as needed (PRN) psychotropic medications (a chemical substance that changes brain function and results in alterations in perception, mood, consciousness or behavior), or specify conditions present to administer the medication for three residents out of 32 sampled residents (Residents #68, #9 and #263). The facility census was 107. Review of the facility's Psychotropic Management Guidelines, dated 7/26/23, showed: -Policy: A psychotropic drug is any drug that affects brain activities associated with mental health processes and behavior. These drugs include but are not limited to drugs in the following categories: Antipsychotic (helps reduce psychotic symptoms like hallucinations, delusions and disordered thinking), Antidepressant, Anxiolytic (helps reduce anxiety), and Hypnotic (sedative, helps induce sleep or treat insomnia); -Residents who use psychotropic drugs receive a Gradual Dose Reduction (GDR) and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent a significant medication error when one resident (Resident #261) was admitted to the facility with an order for an intravenous (IV, into a vein) antibiotic and staff failed to transcribe the antibiotic correctly into the electronic medical record (EMR), which resulted in the resident receiving the medication at the wrong time and he/she received the wrong dose of medication from 1/3/24 through 1/12/24. The sample was 32. The census was 107. Review of the Physicians Orders policy, dated last reviewed 9/28/22, showed: -Policy: To provide guidance and ensure physician orders are transcribed and implemented in accordance with professional standards, state & federal guidelines; -Physician orders shall be provided by licensed practitioners (Physicians, Nurse Practitioners, & Physician's Assistants) authorized to prescribe orders; -Orders must be recorded in the medical record by the licensed nurse authorized to transcribe such orders; -Physician…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow acceptable infection control and prevention practices when staff failed to place a cap on the end of an intravenous (IV, a thin bendable tube that is inserted into a vein that carries fluids and/or medicine) line for one resident (Resident #261) and failed to position one resident's catheter (a flexible tube inserted into the body to remove fluid) drainage bag (bag used to collect urine) off the floor (Resident #12). In addition, staff failed to store one resident's urinary drainage supplies appropriately when not in use (Resident#263). The sample was 32. The census was 107. 1. Review of the facility's Infusion Therapy Medication Administration: Medications Added to Infusion Preparations by the Nurse in the Facility, dated 12/17, showed: -Policy: To provide for the safe, accurate, and effective administration of parenteral medications directly into the vascular system; -The policy did not address if a cap was needed on the end 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 accurately track one resident's antibiotic (Resident #261). This had the potential to affect all residents who were on antibiotics. The sample was 32. The census was 107. Review of the facility's Antibiotic Stewardship Plan policy, dated 4/2017, showed: -The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents; -If an antibiotic is indicated, prescribers will provide complete antibiotic orders including the following elements: drug name; dose; frequency of administration; duration of treatment; start and stop date, or number of days of therapy; route of administration; and indications for use; -When a resident is admitted from an emergency department, acute care facility, or other care facility, the admitting nurse will review discharge and transfer paperwork for current antibiotic orders; -As part of the facility antibiotic stewardship program, all clinical infections treated with antibiotics will undergo review by the Infection Preventionist (IP), or designee. -The IP, or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents had physician orders for dialysis (the clinical purification of blood as a substitute for the normal function of the kidney) and assessment/monitoring of dialysis access sites. The facility failed to ensure residents receiving dialysis were served renal diets (diet to help promote kidney health) in accordance with physician orders, or to ensure residents had physician orders for renal diets as indicated in the residents' hospital discharge summaries. In addition, the facility failed to maintain ongoing communication with dialysis centers for residents receiving dialysis treatment. Four residents were sampled for dialysis and problems were found with all four (Residents #9, #1, #2 and #8). The sample was 15. The census was 107. Review of the facility's Hemodialysis Guidelines policy, undated, showed: -Monitor for bruit (audible vascular sound) and thrill (vibration felt on the skin) every shift. If absent, notify physician…

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 appropriately transferred one resident (Resident #24) using a Hoyer lift (mechanical lift) and two residents (Resident #17 and #50) with a gait belt. The facility also left a medication cart unlocked, unsupervised and accessible to residents. The sample was 21. The census was 92. Review of the facility's Hoyer lift Competency form, provided as the Hoyer lift policy, showed: -Secure the assistance of another nursing assistant or licensed nurse; -Move the lift away from the bed, turn the resident so that he/she faces you while the other assistant guides the resident's body toward the chair by standing behind the resident. 1.Review of Resident #24's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/22/21, showed the following: -Moderate cognitive impairment; -Usually understood or understands; -Extensive assistance of two staff required for bed mobility and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to establish a system for records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation, when the facility failed to properly document narcotic counts for controlled substances, for two out of two nurse medication cart narcotic books reviewed. The census was 97. Review of the Controlled Substance Storage Policy, revised 8/2014, showed: -Policy: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and record keeping in accordance with federal, state and local laws and regulations; -Procedures: -The Director of Nursing (DON) in collaboration with the consultant pharmacist, maintain the facility's compliance with federal and state laws and regulations in the handling of controlled substances. Only authorized licensed nursing and pharmacy personnel have access to controlled substances; -At each shift…

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 biologicals were labeled and stored in accordance with currently accepted professional standards, for two of three nurse medication carts observed. The census was 92. Review of the facility's Medication Administration Preparation and General Guideline policy, revised 8/2014, showed: -Policy: Vials and ampules of injectable medications are used in accordance with the manufacturer's recommendations or the provider pharmacy's directions for storage, use and disposal; -Procedure: -Vials and ampules dispensed by the pharmacy are maintained in the box or container, with the pharmacy label, in which they are dispensed; -Expiration dates: Unopened vials expire on the manufacturer's expiration date. Opening a vial triggers a shortened expiration date that is unique for that product. The date opened and this triggered expiration date are both important to be recorded on the multi-dose vials (on the vial label or an accessory label affixed…

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

Based on interview and record review, the facility failed to provide and maintain complete accounting of records for the resident trust acccount, regarding transaction receipts for clothing in the amount of $1702.19 and $200.00 for one resident (Resident #51). The facility held and managed funds for 21 residents. The census was 92. Review of the facility's updated admission Agreement, showed residents have the right to manage their own personal financial affairs or have someone they trust do so, including the facility. With written approval, the facility will open a personal account for the resident through Resident Fund Management Service (RFMS). This personal resident trust account is controlled by the resident or the resident's representative only. The money placed in the personal resident trust account will accrue interest. We will provide an accounting of these funds upon request, and at least once every three months. Review of Resident #51's resident trust account statement, dated 4/20/20 through 4/19/21, showed the following: -On 9/2/20, Transaction for clothing, $1702.19;…

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 ensure a resident who had an appointed guardian, had verified with the guardian the elected code status for one resident (Resident #17) since assuming guardianship. The sample was 21. The census was 92. Review of the facility's Advanced Directive policy, dated [DATE], showed: -Policy: It is the policy of the facility to respect the resident's right of self-directed care including the right to issue Advanced Directives on health care, to refuse or accept treatment, to make informed decisions, and/or appoint a health care agent to make decision on the behalf of the resident when the resident lacks the capacity to do so; -Each competent adult has the right to control his or her own health care decisions; -Definitions: Guardian: a person appointed by a judge to manage the financial and/or personal matters of a person upon a finding by the court that the person is incapacitated; -Each resident or resident representative will be asked if the resident has…

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 followed their Abuse and Neglect Policy, when staff failed to conduct a thorough investigation into an allegation of missing money when a resident reported to the charge nurse $150.00 went missing from his/her possessions for one resident (Resident #175). In addition, the facility failed to follow their Abuse Prevention, by assessing a resident who wished to participate in a sexual relationship and determining their capacity to consent for one resident (Resident #223). The sample was 21. The facility census was 92. Review of the facility Abuse Prevention Policy, last reviewed 3/20/19, showed the following: -Policy: The facility is committed to protecting the resident from abuse by anyone including, but not necessarily limited to: facility staff, other residents, and staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual;…

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 implement an admission policy or protocol to ensure accurate accounting of residents' personal belongings, to prevent resident liability for resident possessions if items were missing or stolen, when the facility failed complete an inventory list for five of 21 sampled residents (Residents #42, #30, #51, #22, and #17). The census was 92. Review of the facility's undated admission agreement, showed we may not require you or your Resident representative, to agree to waive or limit our liability for loss of personal property suffered as a result of the negligence of our administrator, employees, or agents. However, we are only responsible for loss of personal property that is caused by the negligence of our administrator, our employees, or agents. Because there are many visitors in and out of the facility each day, the facility strongly discourages the keeping valuables or cash unsecured in the facility. Residents are encouraged to keep…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized care plans, to address the specific needs of the residents, for one of 21 sampled residents (Resident #31). The resident was admitted to the facility with a medical history significant for surgical removal of part of the digestive tract. The facility failed to care plan dietary/nutritional problems for the resident. The resident experienced weight loss while at the facility. The census was 92. Review of the facility's comprehensive care plan policy, dated April 2017, showed: -Purpose: Development and implement of a comprehensive person-centered care plan for each resident is that consistent with resident rights, which include measurable objectives and timeframes to meet the medical, nursing, mental, and psychosocial needs that are identified through the comprehensive assessment; -Policy Interpretation and Implementation: The Interdisciplinary Team (IDT), in conjunction with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure staff provided necessary services, care or assistance for dependent residents who were unable to perform self-care hygiene activities of daily living (ADL). Staff failed to provide thorough and appropriate perineal (area from the front of the hips, in between the legs and buttocks) care for two of three observations (Residents #19 and #50). The sample was 21. The census was 92. Review of the facility's Perineal care policy and procedure, dated 1/1/14, showed: -Purpose: To provide cleanliness and comfort to the resident, prevent infection and skin irritation and observe the resident's skin condition; -Procedure: -Cleanse the resident's groin using an approved no rinse incontinence cleaning product; -Separate the groin folds and cleanse on the side, then the other side, then the center of the groin toward the buttocks; -Cleanse the area in a front to back motion; -A clean area of the wash cloth should be used for each area cleaned.…

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.