Arbor Hills Care & Rehab Center

Based on observation, interview and record review, the facility failed to ensure residents were free from significant medication errors for two residents (Resident #52 and #71). The failure placed both residents at risk for adverse effects and compromised therapeutic outcomes when Resident #52 was not monitored during a scheduled nebulizer treatment resulting in the treatment mask falling off the resident and Resident #71 had lidocaine patches applied for longer than recommended by the manufacturer. Sample size 18. The census was 89.1. Review of the state of Missouri Certified Medication Technician (CMT) Student Manual showed administering medications using a nebulizer: The CMT may administer inhaled medications using a nebulizer if permitted by facility policy. Due to variances in equipment, the facility must provide the CMT with training on the operation of the nebulizer system(s) being used in the facility. Documentation of the training and competency in use of the equipment must be placed in the employees' record. During an interview on 2/20/25 at 9:22 A.M., the Corporate Nurse…

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

Based on interview and record review, the facility failed to follow physician orders when staff failed to obtain labs and an x-ray timely for one resident (Resident #3). The sample was 18. The census was 89.Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/12/25, showed:-Severe cognitive impairment;-Functional limitations in range of motion in both upper and lower extremities;-Dependent on staff for Activities of Daily Living (ADL, grooming, dressing and bathing);-Diagnoses included non-Alzheimer's dementia, aphasia (language disorder that impairs a person's ability to speak, understand, read, and write), paraplegia (paralysis that affects all or part of the trunk, legs, and pelvic organs) and multiple sclerosis (MS, a chronic, progressive disease involving damage to the nerve cells);-One stage 2 pressure ulcer (a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough, may also present as an intact or open/ruptured blister);-Three stage 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.

Based on observation, interview, and record review, the facility failed to provide sufficient dietary support personnel to effectively carry out the functions of the food and nutrition services. During one of two kitchen meal service observations, meals were served late and dietary staff failed to follow the menu and serve all menu items due to not having enough dietary staff. The census was 89.During an interview on 2/17/26 at 9:59 A.M., the Assistant Administrator, Director of Nursing (DON), and Corporate Nurse said mealtimes are scheduled for 8:00 A.M., 12:30 P.M., and 6:00 P.M. Review of the Schedule of Mealtimes, showed breakfast in the dining room scheduled at 8:00 A.M., lunch in the dining room scheduled for 12:30 P.M., and supper in the dining room scheduled for 6:00 P.M. Review of the facility's breakfast menu for the date of 2/18/26, showed juice of choice, cereal of choice, egg, biscuit, sausage gravy, skim milk, and coffee or hot tea. Observation of the breakfast meal service on 2/18/26 at 9:06 A.M. showed staff passed drinks in the main dining room. Meal service began…

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 services to identify and treat pressure ulcers (injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or friction) when staff failed to complete daily wound care as ordered for one resident (Resident #6). In addition, the facility also failed to ensure four residents, identified as at risk for development of pressure ulcers, received weekly skin assessments as ordered (Residents #6, #2, #3, and #7). The sample was 8. The census was 73.Review of the facility's Wound Care policy, dated October 2010, showed:-The purpose of this procedure is to provide guidelines for the care of wound to promote healing;-Verify that there is a physician's order for this procedure;-Review the resident's care plan to assess for any special needs of the resident. Review of the facility's Physician and Non-Physician Practitioner Orders policy, dated 1/1/22, showed with changing ways in communication it will be…

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

Based on observation, interview and record review,, the facility failed to ensure one resident's (Resident #2) change in condition was appropriately documented and treated after the resident missed multiple doses of medication. The facility also failed to follow physician orders to order pain medication for one resident (Resident #6). The sample size was eight. The census was 73. Review of the facility's Change in Condition or Status policy, dated 12/2016, showed:-Policy Statement: Our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status;-Policy implementation: The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): accident or incident involving the resident, discovery of injuries of an unknown source, adverse reaction to medication, significant change in the resident's physical/emotional/mental condition, need to alter the resident's medical treatment significantly, refusal of treatment or medications two or more…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that services were provided in accordance with the resident's care plan and accepted professional standards of clinical practices. The facility failed to ensure medications including torsemide (treats fluid retention), Amiodarone (heart medication), Lidocaine 4% patch, and Metoprolol (blood pressure medication) were ordered timely and administered for one resident (Resident #29) who had a diagnosis of congestive heart failure. In addition, the facility failed to ensure the resident was assessed for side rails and document a rationale for the use of side rails. The sample was 11. The census was 83. The administrator was notified on 4/28/25, of the past non-compliance. Staff were in-serviced on the side rail assessment policy and medication administration policy. The deficiency was corrected on 3/5/25. Review of the facility's Medication and Treatment Orders policy, revised July 2016, showed: -Drug and biological orders must be…

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

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored per acceptable standards of practice. The facility identified three nurse medication carts and three medication rooms. Three of the three nurse medication carts were checked, and issues were found with all three carts. Staff failed to store Ativan (lorazepam, a controlled substance used to treat anxiety) liquid medication in the refrigerator, as it is labeled to be stored in the refrigerator, and had it stored in the nurse medication cart narcotic lock box. The sample was 9. The census was 83. Review of the facility's Storage of Medications policy, revised April 2007, showed: -Policy Statement: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. -Policy Interpretation and Implementation: -Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers; -The nursing staff shall be…

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

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Based on observation, interview and record review, the facility failed to ensure facility residents were treated with kindness, dignity and respect. Activity Aide A spoke loudly towards one resident with severe cognitive impairment when the resident dropped a plastic wrapper on the floor (Resident #9). Additionally, direct care staff openly argued and cursed at the nurses' station in front of residents (Residents #12, #13, #14 and #21) about providing showers to residents. The sample was 17. The census was 86. Review of the Resident Right Policy, dated 12/2016, showed: -Policy statement: employees shall treat all residents with kindness, respect and dignity; -Policy Interpretation and implementation: federal and state laws guarantee basic rights to all residents of the facility. These rights include the resident's right to: -A dignified existence; -Be treated with respect, kindness, and dignity; -Self-determination; -Be free from abuse and neglect; -Be supported by the facility to exercise rights without interference, coercion or reprisal from the facility. 1. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to complete a thorough investigation of alleged abuse for one resident (Resident #11) per facility policy. Review of the facility investigation, provided during the onsite investigation, showed it did not include statements from staff or residents. The sample size was 17. The census was 86. Review of the abuse prevention policy, revised 9/16/24, showed: -Investigation: -When an incident or suspected incident of abuse or neglect is reported, the Administrator or designee investigates the incident with the assistance of appropriate personnel; -The investigation should be thorough with witness statements from staff, residents, family members who may be interviewable and have information regarding the allegation; -The investigation may consist of an interview with the person reporting the incident and witnesses, an interview with the resident if possible, a review of the resident's medical record, and interview with staff members having 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure services provided met professional standards for one out of three sampled residents (Resident #1) when staff failed to follow physician orders as written. A urine specimen was not collected until 8 days after ordered by the physician. Antibiotic treatment was also delayed. The census was 84. Review of the facility's Medication and Treatment Orders, revised July 2016, showed: -Policy Statement: Orders for medications and treatments will be consistent with principles of safe and effective order writing; -Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state; -Drug and biological orders must be recorded on the Physician's Order Sheet in the resident's chart. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/03/24, showed: -admitted on [DATE]; -Severely cognitively…

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 the necessary care and services for feeding assistance at mealtime for nutrition and hydration for one of three sampled residents (Resident #2) who required assistance to perform activities of daily living (ADLs). The census was 84. Review of the facility's Assistance with Meals policy, revised July 2017, showed: -Policy statement: Residents shall receive assistance with meals in a manner that meets the individual needs of each resident; -For residents requiring full assistance, nursing will remove food trays from the food cart and deliver the trays to each residents' room; -Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, Review of Resident #2's Registered Dietician note, dated 10/10/24 at 5:40 P.M., showed: -The resident was on regular - mechanical soft diet with thin liquids and was to receive health shakes three times a day (TID), fortified foods TID and was to receive Nutritional Supplement shakes for mid-day and night (HS) snacks; -The resident liked…

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 maintained infection control and proper positioning of the tubing and reservoir bag, for one resident with an indwelling urinary catheter (Foley catheter (a thin, flexible tube inserted into the urethra (the tube that cares urine from the bladder to the outside of the body) to drain urine from the bladder into a collection bag) and recent history of urinary tract infection (Resident #15). The census was 86. Review of the facility's Catheter Care, Urinary policy, dated September 2014, showed: -Purpose: To prevent catheter-associated urinary tract infection (UTIs, infection of the urinary tract system); -Review the resident's care plan to assess for any special needs of the resident; -Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks; -The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder; -Be…

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

See 81JV12 Based on interview and record review, the facility failed to respond to a report that the Business Office Manager (BOM) had been placed on the Employee Disqualification List (EDL, a listing of individuals disqualified from working in a certified nursing home) indicating he/she was ineligible to work in a certified long-term care facility, and continued to employ the staff member. The Department of Health and Senior Services (DHSS) notified the facility on 10/30/24 at 11:45 A.M., that the BOM was permanently placed on the EDL on 10/22/24, and he/she was still working at the facility when surveyors began the investigation on 11/14/24. The census was 95. Review of the EDL Active Report, showed: -The BOM's name and Social Security Number; -Added: 10/22/24; -Ordered Length: Permanent. During an interview on 11/14/24 at 1:41 P.M., the Human Resources (HR) Director said he/she was not aware the BOM had been placed on the EDL. No one notified him/her of the placement. The BOM was currently employed by the facility and had worked as recently as the previous day. The BOM was out 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 81JV12 Based on interview and record review, the facility failed to ensure residents were free from significant medication errors. Staff failed to discontinue a medication used to lower blood sugar as ordered for one resident (Resident #13). The census was 95. Review of the facility's Medication and Treatment Orders Policy, dated 7/2016, showed the following: -Policy: Orders for medications and treatments will be consistent with the principles of safe and effective order writing; -1. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such such medication in this state; -3. Drug and biological orders must be recorded on the physician's order sheet in the resident's chart; -4. All drug and biological orders shall be written, dated and signed by the person lawfully authorized to give such an order; -9. Orders for medication must include: a. Name and strength of the medication. b. Number of doses, start and stop date and or specific duration of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the vehicle used to transport residents was in proper working order, free from debris, and free from exposed wires. This had the potential to affect all residents who used the van. The facility also failed to ensure a completed and thorough investigation was performed and documented after each resident fall for two out of 10 sampled residents (Resident #5 and Resident #6). The census was 86. Review of the facility's Safety and Supervision of Residents policy, undated, showed: -Policy Statement: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities; -Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes. A facility-wide commitment to safety at all levels of the organization. Review of the…

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

Based on interview and record review, the facility failed to respond to a report that the Business Office Manager (BOM) had been placed on the Employee Disqualification List (EDL, a listing of individuals disqualified from working in a certified nursing home) indicating he/she was ineligible to work in a certified long-term care facility, and continued to employ the staff member. The Department of Health and Senior Services (DHSS) notified the facility on 10/30/24 at 11:45 A.M., that the BOM was permanently placed on the EDL on 10/22/24, and he/she was still working at the facility when surveyors began the investigation on 11/14/24. The census was 95. Review of the EDL Active Report, showed: -The BOM's name and Social Security Number; -Added: 10/22/24; -Ordered Length: Permanent. During an interview on 11/14/24 at 1:41 P.M., the Human Resources (HR) Director said he/she was not aware the BOM had been placed on the EDL. No one notified him/her of the placement. The BOM was currently employed by the facility and had worked as recently as the previous day. The BOM was out 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 residents were free from significant medication errors. Staff failed to discontinue a medication used to lower blood sugar as ordered for one resident (Resident #13). The census was 95. Review of the facility's Medication and Treatment Orders Policy, dated 7/2016, showed the following: -Policy: Orders for medications and treatments will be consistent with the principles of safe and effective order writing; -1. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such such medication in this state; -3. Drug and biological orders must be recorded on the physician's order sheet in the resident's chart; -4. All drug and biological orders shall be written, dated and signed by the person lawfully authorized to give such an order; -9. Orders for medication must include: a. Name and strength of the medication. b. Number of doses, start and stop date and or specific duration of therapy. c.…

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 a resident with outlined food preferences to meet the needs of one of 3 sampled residents (Resident #4). The census was 86. Review of the facility's Tray Identification policy, undated, showed: -Appropriate identification shall be used to identify various diets; -To assist in setting up and serving the correct food trays/diets to residents, the Food Service Department will use appropriate identification to identify the various diets. Review of Resident #4's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/20/24, showed: -Understood, understands, clear comprehension; -Cognitively intact. Review of the Resident #4's care plan, dated 6/21/24, showed: -Assess the resident's likes and dislikes and attempt to accommodate; -No pork, no cooked tomatoes or carrots; -Prefers fresh vegetables and fruits, doesn't like cooked carrots or tomatoes. He/She prefers fish, chicken, and turkey. Turkey sausage and bacon. He/She prefers no gravy on his/her…

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

Based on interviews, review of the Payroll Based Journal (PBJ) staffing report, and nursing schedules from 10/01/23 to 12/31/23, the facility failed to ensure the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for 22 of the 92 days reviewed. Failure to have an RN on duty for eight consecutive hours a day has the potential to affect the care provided to residents and the supervision of the unit. Findings include: Review of the PBJ, for the fiscal year quarter one of 2024, revealed no RN hours triggered for four or more days October, November, and December 2023. Review of the facility's Nursing Schedules, dated from 10/01/23 through 12/31/23, revealed no RN coverage on 10/01/23, 10/07/23, 10/15/23, 10/28/23, and 10/29/23. In November 2023 there was no RN coverage for 11/04/23, 11/05/23, 11/11/23, 11/12/23, 11/18/23, 11/19/23, 11/25/23, 11/26/23. In December 2023 there was no RN coverage for 12/02/23, 12/03/23, 12/09/23, 12/10/23, 12/16/23, 12/23/23, 12/24/23, 12/25/23, and 12/31/23. During an interview on 04/30/24 at 4:00 PM, the…

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

Based on interview and record review, the facility failed to develop, initiate, or revise, if necessary, a facility assessment to determine what resources were necessary to care for its residents competently during day-to-day operations. The lack of an adequate facility assessment had the potential for residents' needs to go unmet and/or result in a lack of services provided by the facility to competently care for 78 residents who resided at the facility at the time of the survey. Findings include: During the entrance conference on 04/29/24 at 10:15 AM with the Director of Nursing (DON), the Facility Assessment was requested. As of 04/30/24 at 4:30 PM, the Facility Assessment had not been provided. During an interview on 04/30/24 at 4:30 PM, regarding the Facility Assessment, with the Administrator and DON, the Administrator asked .What is a Facility Assessment? . This surveyor provided a verbal description of a Facility Assessment and the Administrator stated they did not have one, nor were they asked to provide one during their initial certification in January 2022, or on any 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 policy review, the facility failed to develop a Quality Assurance and Performance Improvement (QAPI) program. This had the potential to affect 78 of 78 residents who resided at the facility. Findings include: Review of the facility's Quality Assurance Improvement Plan, dated February 2020, revealed, .The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include A. Tracking and measuring performance, B. Establishing goals and thresholds for performance measurement, C. Identifying and prioritizing quality deficiencies, D. Systematically analyzing underlying causes of systemic quality deficiencies, E. Developing and implementing corrective action or performance improvement activities, and F. Monitoring or evaluating the effectiveness of corrective action/performance improvement activities and revising as needed . During an interview on 05/01/24 at 2:05 PM the Director of Nursing (DON) stated the facility did not have a QAPI plan. During an interview on 05/02/24 at 2:15 PM, the Administrator and DON…

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 review of facility documentation, the Quality Assurance (QA) committee failed to identify quality deficiencies, , develop or implement corrective actions, , track, and measured for effectiveness or develop new interventions based on the QA committee discussions. This failure had the potential to affect 78 of 78 residents who resided at the facility. Findings include: Review of facility policy titled Quality Assurance and Performance Improvement (QAPI) Program, dated February 2020, revealed . This facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven (QAPI) program that is focused on indicators of the outcomes of care and quality of-life for our residents. and .Provide a means to measure current and potential indicators for outcomes of care and quality of life. During an interview on 05/01/24 at 2:05 PM the Director of Nursing (DON) stated the facility did not have a QAPI plan. During an interview on 05/02/24 at 12:30 PM, the DON stated the QA committee had not identified any specific quality deficiencies for performance…

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 review of facility documentation, the Quality Assurance (QA) committee failed to meet, at least quarterly, with the required members resulting in the potential for missed opportunities with identifying, tracking, and measuring quality deficiencies. This failure had the potential to affect 78 of 78 residents who resided at the facility. Findings include: Review of facility policy titled Quality Assurance and Performance Improvement (QAPI) Program, dated February 2020, revealed . The committee meets monthly to review reports, evaluate data, and monitor QAPI related activities and make adjustments to the plan. The DON provided two QA committee sign in sheets for 11/18/22 where the DON, Infection Preventionist (IP), and Medical Director did not attend. The 09/28/23 sign in sheets revealed the Administrator and Medical Director did not attend. During an interview on 05/02/24 at 12:30 PM, the DON confirmed there have only been two QA meetings since the initial certification survey in January 2022. The DON also stated there have not been any QA meetings for 2024, nor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure resident funds were placed in an account separate from the facility operating account. The facility did not provide residents with refunds of their personal funds from the operating account in a timely manner for six residents (Residents #1016, #1019, #1027, #1028, #1029, and #1030). Secondly, the facility staff failed to obtain written authorization from the resident and/or financial guardian for money withdrawn for 19 residents (Resident #1001, #1002, #1003, #1004, #1005, #1006, #1007, #1008, #1009, #1010, #1011, #1012, #1013, #1014, #1015, #1019, #1020, #1023, and #1025) out of a sample of 20. Thirdly, the facility staff failed to provide the Social Security and/or Medicaid monthly allowance in a timely manner, which did not allow the resident/financial guardian the right to manage all of his/her financial affairs for seven residents (Resident #1001, #1004, #1005, #1008, #1009, #1010, and #1013) out of a sample of 10. Fourthly, the facility…

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

Based on record review and interview, the facility failed to maintain a system to ensure the resident trust fund account was managed in accordance with proper accounting principles by not maintaining an accurate accounting of all monies held in the resident trust fund account by not reconciling each month. The facility managed funds for 21 residents. The census was 80. 1. Record review of the facility maintained bank statements for account ending in #5015 for months 03/2023 through 12/2023 and 02/2024 - 03/2024 showed no documentation of reconciliations. Record review of the facility maintained attempted reconciliation forms for account ending in #5015, dated 09/2023 and 03/2024, showed the attempted reconciliations did not reconcile to the residents' current balance at the time of reconciliation. During an interview on 05/10/24 at 3:37 P.M., the Business Office Manager said he/she did not start reconciling the account until 08/2023 and continued to say the accounts were reconciled, but did not have any other documentation to provide.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide a final accounting of resident fund balances within thirty days to the individual or probate jurisdiction administering the resident's estate for one discharged resident (Resident #1020) out of a sample of three discharged and four expired residents (Resident #1019, #1023, #1025, and #1026) out of a sample of five expired. The facility census was 80. 1. Record review of the facility maintained Trust Transaction History Report dated [DATE], showed Resident #1020 discharged on [DATE]. Record review of the facility maintained Trust Transaction Report for the period [DATE] through [DATE], showed Resident #1020 had $30.00 deposited on [DATE] and was not refunded as of [DATE], 33 days after discharge date . During an interview on [DATE] at 1:54 P.M., the Business Office Manager said he/she did not know why the $30 had not been refunded. 2. Record review of the facility maintained Discharge Report dated [DATE], showed Resident #1019 expired on [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.

Based on interview and record review, the facility failed to maintain an adequate surety bond for the resident trust fund account in the amount of one and one half times the average monthly balance for the past 11 months. The census was 80. Review of the resident trust account for the past 12 months, from March 2023 through February 2024, (excluding the December 2023) showed an average monthly balance of $26,000.00 (this would yield a required bond in the amount of $39,000.00 (one and one half times the average monthly balance)). Review of the bond report for approved facility bonds by the Department of Health and Senior Services (DHSS), showed an approved bond of $4,000.00, dated 8/23/21. Review of the resident trust current balance report for February 2024, showed an amount of $13,782.56 in the trust account. During an interview on 5/7/24 at 11:30 A.M., the Business Office Manager (BOM) said the Administrator was in charge to ensure the surety had the appropriate amount. The BOM did not know how often the Administrator reviewed the surety bond. They do not have a policy for the…

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

Based on observations and interviews, the facility failed to post the location of the state survey results and provide unrestricted access to residents and visitors, resulting in the potential for current residents, visitors, and potential residents not to be able to review the survey results and the facility's plans of correction (POC). Findings include: Observations conducted throughout the facility from 04/29/24 to 05/01/24 revealed no notices posted in the facility to notify residents or visitors where the survey results binder was located. A binder labeled Survey Results was located behind the front desk on 04/29/24 when the survey team entered. Review of the Survey Results binder on 05/01/24 revealed documentation from a Targeted Infection Control survey completed on 04/18/22. The documentation did not contain the facilities POC. During an interview on 04/30/24 at 4:30 PM, the Administrator and Director of Nursing (DON) stated the Survey Results binder was kept behind the receptionist's desk. The Administrator stated a binder had been placed in the lobby area at one time, but…

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, record review, and facility policy review, the facility failed to issue an accurate Notice of Medicare Non-Coverage (NOMNC) when Medicare Part A service was ending for three of three residents (Residents (R) 1, R25, and R67) reviewed out of a total sample of 24 residents. This failure could have led the residents or their responsible party to miss the deadline to request an expedited appeal and review. Findings include: The facility used the directions for completion of the NOMNC from the Centers for Medicaid and Medicare Services (CMS) form number CMS-10123 as their policy. The directions indicated that in the heading and first two bullet points of the NOMNC the form was to read, .The effective date your {insert type} services will end: {insert effective date}: Fill in the type of services ending, {home health, skilled nursing, comprehensive outpatient rehabilitation services, or hospice} and the actual date the service will end. The portion of the NOMNC detailing how to ask for an immediate appeal was to include, .Insert the name and telephone numbers…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure three residents (Residents #1008, #1010, and #1019) were free from misappropriation of resident property when the Business Office Manager used resident funds for his/her personal use. The census was 80. 1. Record review of the facility maintained Trust Transaction Report for the period 05/01/23 through 05/07/24, showed a withdrawal from Resident #1019's account: Date Amount Description 10/10/23 $5,175.00 Funeral Home Record review of the facility maintained documentation showed check #1046 in the amount of $5,175.00, dated 10/10/23, made payable to Resident #1019's family member. Record review of the facility maintained documentation showed the Business Office Manager provided a Statement of Funeral Goods and Services Selected from a funeral home in Maplewood, MO showing the following: -Resident #1019's handwritten name at the top of the form -The Statement was originally dated 05/01/2018 at the top of the bill and showed the bill was paid 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.

Based on interview and record review, the facility failed to ensure newly hired employees were screened to rule out the presence of a Federal Indicator, with the Certified Nurse Aide (CNA) Registry for three staff members. In addition, the facility failed to check for nursing licensing for one Registered Nurse (RN) and three Licensed Practical Nurses (LPN). A sample of 10 employees hired were reviewed. The facility hired at least 200 new employees since the last survey. The census was 80. Review of the facility's Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating Policy, dated April 2021, showed the following: -Policy: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported; -Review of the facility's policy showed no documentation regarding employee screening for background…

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

Based on observation, interviews, and review of facility policy, the facility failed to ensure daily staffing was posted timely and in a manner that visitors and residents had access to this information. This deficient practice has the potential to affect all residents and visitors. Findings include: Review of the facility's policy titled, Posting Direct Care Daily Staffing Numbers revised July 2016, indicated, .Within two (2) hours of the beginning of each shift, the number of Licensed Nurses (RNs, LPNs, and LPN's) and the number of unlicensed personnel (CNA's) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format . Upon entrance to the facility at 9:00 AM, no daily staff posting of nursing hours was visible anywhere in the building. Tour of the building at 2:00 PM revealed no posting of the daily nurse staffing hours anywhere. During observations on 04/29/24 at 10:30 AM and 2:00 PM, no daily staff posting of nursing hours was visible anywhere in the building. During observations on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews, the facility failed to maintain a complete and accurate medical record to include required Preadmission Screening and Resident Review (PASRR) Level I and Level II, if applicable, evaluations for mental illness or intellectual disabilities for three of 24 sampled residents. This failure to have the PASRR screening results increased the risk that residents with mental illness or intellectual disabilities would not get all the required specialized services in the facility. Findings include: 1. R54 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia and history of traumatic brain injury sustained during an arrest. Review of R54's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 04/14/24 revealed a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderate cognitive impairment. R54 was ambulatory via wheelchair. He did not participate meaningfully in interviews when attempted, but…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, and facility policy review, the facility failed to report to the State Survey Agency (SA) a verbal threat to shoot residents and staff in the facility by one of six residents (Resident (R)54) reviewed for abuse out of a total of 24 sampled residents. This failure increased the risk that additional verbal threats would continue without the SA's knowledge and opportunity to investigate. Findings include: Review of the facility's policy titled Abuse Investigation and Reporting revised December 2016, revealed Policy Statement - All reports of resident abuse, neglect .mistreatment shall be promptly reported to local, state, and federal agencies and thoroughly investigated by facility management. Findings of abuse investigations will also be reported . R54 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia and history of traumatic brain injury sustained during an arrest. Review of R54's quarterly Minimum Data Set (MDS) assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, and facility policy review, the facility failed to thoroughly investigate a threat to shoot residents and staff in the facility verbalized by one of six residents (Resident (R)54) reviewed for abuse out of a total sample of 24 residents. This failure to thoroughly investigate the verbal threat to shoot staff and residents increased the risk of the threat actually being carried out by R54. In addition, the facility failed to thoroughly investigate an allegation of misappropriation in accordance with their policy. The facility did not suspend the employee promptly and re-instated the employee prior to speaking with all potential witnesses. In addition, the employee accused of misappropriation made contact with one of the residents one more than one occasion, including in person. Findings include: Review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating revised April 2021, showed: -Policy Statement - All…

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 issue one of three residents (Resident (R) 1) or responsible party a notice of transfer when R1 was sent to the emergency room. Findings include: Review of R1's Face Sheet located in the Profile tab of the electronic medical record (EMR) revealed he was initially admitted on [DATE] for long-term care. Among his diagnoses on his Face Sheet were Type 2 diabetes mellitus and dementia. Review of the Documents tab of the EMR revealed there were no documents uploaded reflecting a transfer notice was provided to R1 when he was sent out on 04/13/24 for a hypoglycemic (low blood sugar) event. An interview was attempted with R1 on 05/01/24 at 1:30 PM however he did not respond. On 05/02/24 at 10:44 AM a second interview was attempted with R1 with no response from him. On 05/02/24 at 2:39 PM an interview with the social worker (SW) verified there was no written transfer provided to R1. The facility was unable to provide a policy for issuing a written notice to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to issue one of three residents (Resident (R) 1) or their responsible party out of a total sample of 24 residents a bed hold notice when R1 was sent to the emergency room. Findings include: Review of R1's Face Sheet located in the Profile tab of the electronic medical record (EMR) revealed he was initially admitted on [DATE] for long-term care. Among his diagnoses on his Face Sheet were Type 2 diabetes mellitus and dementia. Review of the Documents tab of the EMR revealed there were no documents uploaded reflecting a bed hold form was provided to R1 when he was sent out on 04/13/24 for a hypoglycemic (low blood sugar) event. An interview was attempted with R1 on 05/01/24 at 1:30 PM however he did not respond. On 05/02/24 at 10:44 AM a second interview was attempted with R1 with no response from him. On 05/02/24 at 2:39 PM an interview with the social worker (SW)verified that no bed hold notice was provided to R1 upon transfer to the hospital. The facility…

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, record review, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to accurately code one of 24 residents (Resident (R) 61) for restraints. This failure placed the resident at risk for the use of restraints. Findings include: Review of the document titled, MDS (Minimum Data Set) 3.0, Care Assessment Summary and Individualized Care Plans revealed the directions for completing the MDS Section P for restraints. The section stated .discusses the various types of restraints.how to assess a resident for physical restraint. The document was not dated. R61 was observed on 05/01/24 at 3:30 PM in her room sitting on the side of her bed. She was transferring herself to the wheelchair. There were no restraints on the wheelchair or her bed. Interview with the MDS Coordinator on 05/01/24 at 3:45 PM confirmed R61 did not have any restraints at any time during her stay in the facility. She stated, It's an error. Review of the quarterly MDS with an Assessment Reference Date (ARD) of 02/13/24 revealed R61 was coded in the section titled,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, record review, and policy review, the facility failed to reassess interventions for efficacy when the current behavior management interventions (both medications and nonpharmacologic interventions) were not effective in decreasing verbally and physically abusive behaviors towards other residents and staff in one of five residents (Resident (R) 54) reviewed for psychosocial and behavior management out of a total sample of 24 residents. This failure increased the risk of ongoing abusive behaviors towards residents and staff by R54. Findings include: Review of the facility's policy titled Behavioral Health Services revised February 2019 revealed, The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being for each resident .7. Staff are scheduled in sufficient numbers to manage resident needs during the day, evening and night .11. The DON, 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 interview and record review, the facility failed to ensure that monthly medication regimen reviews were completed by the consulting pharmacy for two of 24 sampled residents (Resident (R)22 and R25), resulting in the potential for adverse side effects from unnecessary, or duplicate, medications. Findings include: 1. Review of R22's admission Record (undated), located under the Profiles tab in the electronic medical record (EMR) revealed R22 was admitted to the facility on [DATE] with diagnoses which included of dementia with agitation, major depressive disorder, and cognitive communication deficit. Review of R22's quarterly Minimum Data Set Assessment (MDS), located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 04/06/24 revealed R22, had a Brief Interview for Mental Status (BIMS) of zero which indicated R22 was severely cognitively impaired. Review of R22's Medication Administration Records (MAR) dated December 2023 revealed R22 had an order for .Haldol 5 milligrams (mg) by…

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 that medications ordered on an as needed (PRN) basis for two of 24 sampled residents (Resident (R)22 and R25), included a stop date no later than 14 days after receipt of the order, resulting in the potential for adverse side effects from unnecessary medications. Findings include: Review of the facility's policy titled, Administering Medications, revised 12/12, revealed, .If a resident uses PRN medications frequently, the Attending Physician and Interdisciplinary Care Team, with support from the Consultant Pharmacist as needed, shall reevaluate the situation, examine the individual as needed, determine if there is a clinical reason for the frequent PRN use, and consider whether a standing dose of medication is clinically indicated . 1.Review of R22's admission Record (undated), located under the Profiles tab in the electronic medical record (EMR) revealed R22 was admitted to the facility on [DATE] with diagnoses of dementia with agitation, major…

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 notify a resident's responsible party after new skin conditions, which required treatment, were identified, for one of 10 sampled residents (Resident #1). The facility census was 69. Review of the facility's Changes in Condition Notification policy, revised 11/2022, showed: -It is the responsibility of licensed staff to contact the physician and the resident's responsible party whenever there is a change in the resident's physical, mental, or psychosocial status; -A change in condition is any assessment finding, observance, or event that deviates or has the potential to cause a deviation in the resident's usual or expected physical, mental, or psychosocial status; -Except in situations where a medical emergency exists, all notifications will be made within 24 hours of the noted change; -Upon identification of a change in condition, licensed nursing personnel will contact the resident's responsible party to inform them of the change. Review of Resident…

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

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 staff failed to ensure a resident who receives hemodialysis (a procedure that filters wastes, salts and fluid from the blood when the kidneys are no longer healthy enough) received ordered medication to treat elevated potassium levels. The staff also failed to consult with the ordering physician on suggested medication alternatives, so the resident could begin the medication. As a result, the resident did not receive the ordered medication and the resident's blood potassium level increased (Resident #4). The potassium level increased and was detected by the dialysis staff. When the dialysis staff inquired about the ordered medications to treat elevated potassium levels, the facility staff stated the medications were not provided to the resident. The sample was four. The census was 68. Review of the Medication Administration policy, revised 12/2012, showed: -Policy: medications shall be administered in a safe…

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 do neurological checks (neuro-checks, an assessment completed by nursing staff to monitor for changes in the resident's neurological (nervous system) status) in accordance with the facility's policy for a resident with repeated falls (Resident #4). The sample was 12. The census was 60. Review of the facility's Falls-Clinical Protocol policy, revised March 2018, showed: -Assessment and recognition: After a fall the nurse shall assess and document/report the following: -Vital signs; -Recent injury, especially fracture or head injury; -Musculoskeletal function, observe for change in normal range of motion (ROM) and weight bearing; -Change in condition and level of consciousness; -Neurological status; -Pain; -Frequency and number of falls; -Precipitating factors and details on how fall occurred; -Current medications, specifically those associated with dizziness or lethargy; -Active diagnoses; -The policy did not show how often and how long neuro-checks should be completed. Review of a computer generated Neurological…

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 document assessment of pain and effectiveness of pain relief medications and provide pain management in accordance with the resident's physician orders (Resident #7). The sample was 12. The census was 60. Review of the facility's pain assessment and management procedure, revised 3/2015, showed: -Purpose: The purpose of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain; -General Guidelines: -2. Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals; -3. Pain management is a multidisciplinary care process that includes the following: -a. Assessing the potential for pain; -b. Effectively recognizing the presence of pain; -c. Identifying the characteristics of pain; -d. Addressing the underlying causes of the pain; -e.…

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.