St Sophia Health & Rehabilitation Center

Based on interview and record review, the facility failed to ensure services provided met professional standards when staff failed to obtain a repeat weight as requested by the dietician for one resident (Residents #9) after the resident was noted to have significant weight loss. The facility also failed to ensure requested labs from an outside provider were completed and followed up on timely for one resident (Resident #4). The sample was 9. The census was 165.1.Review of Resident #9's medical record, showed diagnoses include diabetes, aphasia (difficulty communicating), dysphagia (difficulty swallowing), dementia, and delusional disorder. Review of the resident's care plan, in use at the time of the investigation, showed:-Focus: Resident has nutritional problem or potential nutritional problem related to multiple comorbidities and age/diagnosis process;-Goal: Resident will maintain adequate nutritional status as evidenced by maintaining weight within 5-10% of usual weight no signs/symptoms of malnutrition, and consuming at least 75% of at least 2-3 meals daily through review…

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 followed their Enhanced Barrier Precautions (EBP) policy when a staff member assisting with wound care did not wear an item of personal protective equipment (PPE), which was the gown, for one resident (Resident #5). Further review of the medical record, showed the resident was not ordered to be on EBP Precautions despite multiple open areas. The sample was 9. The census was 165. Review of the facility's Enhanced Barrier Precautions policy, last reviewed 5/15/24, showed:-Policy: The facility may expand the use of PPE and refer to the use of gowns and gloves during high-contact care activities that provides opportunities for transfer of multi-drug resistant organisms (MDROs) to hands/clothing. The use of gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for facility residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection/colonization.-Responsibility: Direct Care…

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 medical records containing protected health information (PHI) were not accessible to individuals who do not have the right to view the protected health information, for one resident (Resident #23) when staff provided an after-visit summary for Resident #23 to the family of a different resident. The facility census was 159.Review of the Know Your Rights statement, posted at the front entrance of the facility showed resident rights included confidentiality. Medical, personal, social or financial affairs should be considered privileged information. During an interview on 12/31/25 at 1:30 P.M., the family member for Resident #10 said a couple weeks ago on December 17th, the resident's nurse handed him/her the after-visit summary for Resident #23. The family member told the staff person about the mistake, and the staff person told the family member that he/she did not care and did not want the paperwork back and the family member could do whatever he/she wanted to with the documents. The family member still…

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 homelike environment for two residents sampled (Resident #10 and Resident #12) by not keeping Resident #10's room swept daily and having a bedside table with screws sticking out of the table. The facility staff also left two plates stacked by the air conditioning unit in Resident #12's room over a period of two days. The plates had dried food on them. In addition, the facility failed to ensure a sufficient number of plates were available to provide a homelike environment, providing Styrofoam plates in place of dining plates (Residents #6 and #7). The facility census was 159.Review of the facility's Resident's Rights Policy, last reviewed 4/26/23, showed the facility shall treat Residents with kindness, respect, and dignity and ensure Resident Rights are being followed:-Upon admission to the Facility the Resident and/or Resident Representative will be informed of the residents' bill of rights. Resident/Resident representative will sign the residents' bill of rights acknowledgement;-A copy 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 establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation, when the narcotic count sheet for one resident was lost, resulting in 30 narcotic pain pills with no reconciliation (Resident #12). The census was 159. Review of the Controlled Substance Storage Policy, revised 03/2017, showed:-Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal, state and other applicable laws and regulations.-Procedures:-The director of nursing, in collaboration with the consultant pharmacist, maintains 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.-A controlled substance accountability record is prepared by the pharmacy/facility for all Schedule…

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 in a manner to prevent the risk of accidents and injury for one resident who was transferred without using a mechanical lift as ordered and according to the resident's plan of care (Resident #1). The census was 170. Review of the facility's Total Lift Transfer policy, dated 11/28/22, showed the facility will utilize a total lift device on residents who are unable to assist with transfers:-Full Body Lift: A lifting device used to provide safety of the resident/employees during transfers.-Procedure: Measure resident for appropriate sling size according to manufacturer. Position the sling under the resident with the base of the sling at the base of the resident's spine, top of the sling at the top of the head, cross straps prior to hooking the straps of the lift. Match the corresponding colors on each slide of the sling & observe that all sling loops are securely connected. Standing next to the Resident, press the up button on the lift controls to slowly raise the Lift to the height necessary 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.

Based on interview and record review, the facility failed to ensure nursing staff working in the facility were licensed to practice in the state of Missouri, when a Licensed Practical Nurse (LPN) on duty, who obtained their nursing license in a different state was working as a LPN in the facility with no Missouri nurses license. This had the potential to affect all residents. The census was 170.Review of the facility's current Human Resources (HR) General Position Information, showed graduated practical nurses (GPN, an individual who had graduated from nursing school to work as an LPN but had not yet passed the nursing boards) may only work for maximum of 90 days following graduation date. Review of Nursys Quick Confirm License Verification Report (the national database for nurse licensure verification, discipline, and practice privileges, created and operated by the National Council of State Boards of Nursing), showed LPN D not listed as licensed in the state of Missouri. He/She was only licensed and authorized to practice in Illinois state, with license original issue date of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure staff implemented their Abuse Prevention Policy by not conducting a thorough investigation and report to the state survey agency as required, when two residents had a physical altercation (Residents #24 and #25). The sample was eight. The census was 171.Review of the facility's Abuse Prevention Policy, dated 10/21/22, showed the following:-Policy: The facility is committed to protecting the residents 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;-Definition: -Abuse: Willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, mental anguish, or emotional distress. This includes the deprivation by an individual, including a caretaker of goods or services that are necessary 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.

Based on observation, interview and record review, the facility failed to follow the facility's policy, and notify the physician and the Registered Dietician (RD) of an 11.5-pound (lb) weight loss in 56 days for one resident (Resident #17). The sample was eight. The census was 171. Review of the facility's Weight Variances Policy, dated 3/31/21, showed the following:-Policy: All residents who experience significant, insidious and/or unintentional/unplanned weight loss or gains shall be assessed for nutritional status by Registered Dietitian. Recommendations from Registered Dietitian to include but not limit to adding calorie rich/preferred snacks between meals, fortification, supplements, liberalizing diet, and plan for expected weight changes; -Residents receiving supplements shall be monitored for acceptance by the Dietary Manager/Nursing Staff. Residents at risk for unintentional/unplanned weight variance may be monitored with weekly weights. Weights shall be reviewed by the Registered Dietitian for review and assessment;-Responsibility: Nursing Personnel, RD, Dietary Personnel…

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 consistently notified physicians when blood glucose/sugar levels (the concentration of glucose in the blood) exceeded the parameters ordered by the physician or the parameters in accordance with the facility's policy. In addition, the facility failed to ensure staff consistently documented blood glucose levels on the Medication Administration Record (MAR) and/or failed to ensure staff documented explanations when they used the codes NA (not administered, see nurses notes), NI (no insulin required) or HD (hold, see nurses notes) on the MAR. The facility identified 48 residents with routine blood glucose monitoring. Of those 48, eight were sampled and problems were found with four (Residents #8, #15, #16 and #17). The census was 170.Review of the facility's Notification Of A Change In A Resident's Condition policy, approved on 11/1/18 and last reviewed on 4/28/21, showed:-Policy: The attending physician and the Resident Representative will…

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 oral care supplies (toothbrush, toothpaste and mouthwash) for their use in their rooms and failed to ensure staff provided oral care to residents. Twenty-three residents were sampled. Of those 23, five were interviewed and three said they did not have oral care supplies and staff did not offer to provide oral care (Residents #18, #8 and #15). The census was 170.Review of the facility Oral Hygiene policy, approved on 4/28/22 and last reviewed on 7/21/22, showed:-Policy: The Facility will provide Oral Hygiene to Residents as directed in the Plan of Care. Oral Care will include cleansing the Oral Cavity and removing Food/Debris; This may reduce Odor, Infection and provide Comfort;-Responsibility: Nursing Assistant (Certified Nursing Assistant (CNA), Licensed Nurses (Licensed Practical Nurses (LPNs) and Registered Nurses (RNs)), Nursing Administration, and Director of Nursing (DON);-Equipment Includes: Toothbrush,…

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 referred to the restorative program from the therapy department received the services according to the restorative therapy plan. The facility identified 19 residents receiving restorative services. Four of these residents (Residents #1, #21, #22, and #23) had a restorative exercise plan developed by the therapy department, and they were not receiving services as prescribed by skilled therapy. The facility had a census of 170.Review of the facility's Restorative Nursing Care policy dated 1/1/2014, showed: ~ Restorative care refers to nursing interventions that promote the resident ability to adapt and adjust to living as independently and safely as possible.~ It is the policy of this facility to utilize the interdisciplinary restorative team in promoting optimal function for all residents, for the appropriate restorative program per their assessment of their functional needs. All residents who have an identified restorative…

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 necessary Social Services (SS) by failing to promptly develop a discharge plan and/or seek professional medical and/or psychiatric evaluation(s) to determine if one resident had the right to discharge to the community with or without a place to reside, discharge against medical advice (AMA), or if the facility should seek legal advice about legal guardianship for the resident. The resident, who was homeless, but his/her own legal representative, was admitted to a local hospital on 4/13/25, for a medical condition and was then discharged to the facility on 4/30/25. The resident's diagnoses included bipolar disorder (characterized by periods of depression and periods of abnormally elevated mood) and anxiety. On 5/2/25, the resident was placed on a locked unit within the facility after expressing his/her desire to leave and attempting to leave. (Resident #2) The census was 170. Review of the facility Social Service Supervisor job…

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 hot water at fixtures accessible to residents located in resident rooms on the 200 hall is maintained between the regulatory temperature range of 105 degrees Fahrenheit (F) and 120 degrees F. The deficient practice had the potential to affect 44 residents residing on 200 hall. The census was 175. Review of the facility's water temperature regulation for residential programs policy, revised 1/29/13, showed:-The comfort and preferences of the individual are balanced with the abilities and safety of the individual. This is outlined in the individual's plan;-1. The ability and safety risk of everyone receiving residential services related to management of water temperatures should be documented in the individual's plan;-The considerations to screen and document for safe management of water temperatures would include, but not be limited to: -a. Physical ability to manipulate faucets/ handles to control the mixture of hot and cold water…

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 comprehensive care plans to address specific needs of the residents for four sampled residents. (Resident #1, Resident #2, Resident #7 and Resident #8). The census was 175.Review of the facility's Comprehensive Person-Centered Care Plan policy, last reviewed 10/23/19:-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;-Definitions: -Interdisciplinary Team (IDT): All disciplines will collaborate to develop a plan of care that meets the residents' needs, preferences, and goals; -Baseline Care Plan: Is the baseline plan of care and is developed within 48 hours of admission and updated with a change in resident condition as applicable until completion of the comprehensive care plan; -Comprehensive Person Centered Care Plan (CCP): Contains…

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 appropriate interventions for falls for one resident (Resident #6) who had no fall mats next to the resident's bed. The facility failed to adequately assess resident falls by ensuring residents received treatment and care in accordance with acceptable standards of practice when the facility failed to accurately complete post (after) fall 72 hour monitoring report (neurological (neuro) evaluation - pulse (P), respiration (R), and blood pressure (BP) measurements; assessment of pupil size and reactivity; and equality of hand grip strength) if the fall was unwitnessed or if the resident had an incident in hitting their head (Residents #6 and #5), and failed to complete incident follow up documentation (IFU) for 72 hour post fall in the progress notes each shift, for three of three residents sampled (Residents #6, #5 and #4). In addition, the facility failed to maintain water temperatures so they did not exceed 120 degrees Fahrenheit…

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 residents who received dialysis (the process of filtering the blood for individuals with kidney failure) services had current dialysis orders that included the location for the dialysis services for one resident (Resident #2), the days of week the resident would go to dialysis and what the dialysis chair time was for two residents (Resident #2 and Resident #8). The facility also failed to ensure the dialysis services had been addressed on the resident's individual care plan for chair time for three residents (Resident #2, Resident #8 and Resident #7). Additionally, the facility failed to contact and document the notification to the physician and resident representative (RR) when the resident refused dialysis or when the dialysis treatment ended early for three of three residents (Resident #2, #7 and #8). The census was 175.Review of the facility's Hemodialysis (HD, medical treatment for kidney failure that uses a machine to filter waste products and excess fluid from the blood) protocol policy, reviewed 10/25/24,…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide reasonable accommodations of individual needs and preferences when staff denied access to the adjoining bathroom for two residents (Residents #6 and #17). Staff removed the bathroom doorknobs on two-bathroom doors of the adjoining bathroom to prevent the two residents from having access to the toilet. Staff did not know which resident may have clogged the bathroom toilets. This required the residents to ask staff to unlock the main bathroom on the hall when they needed to void of urine or have a bowel movement. The sample was 18. The census was 160. 1. Review of Resident #6's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/4/25, showed: -Moderate cognitive impairment; -Wheelchair; -Toilet hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement, dependent; -Toilet transfer: The ability to get on and off 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 observation and interview, the facility failed to provide a safe, clean, comfortable and homelike environment when staff did not clean and maintain sanitary conditions in an adjoining resident bathroom for two residents (Resident #6 and Resident #17). The sample was 17. The census was 160. Review of the facility's Safe Homelike Environment policy, last reviewed 4/28/22, showed: -Policy: In accordance with resident's rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk; -Definitions: -Environment refers to any environment in the facility that is frequented by residents, including (but not limited to) resident's room, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activity…

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 eight of 33 sampled residents were provided a homelike environment by failing to ensure resident toilets were clean (Residents #8 and #119), resident rooms had clean floors (Residents #8, #119, #38, #62, and #15), soap dispensers in resident rooms were full (Residents #20 and #140) and residents had clean bedding (Resident #119). The facility also failed to ensure residents' furniture and medical equipment were in working order and clean (Residents #62, #105, and #15), and that the 400 hallway dining room had clean floors. The census was 166. Review of the facility's safe homelike environment policy, dated 4/28/22, showed: -Policy: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment; -Procedure: Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. The facility will provide and maintain bed and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure Activities of Daily Living (ADL) care was provided to four of 33 sampled residents. The facility failed to ensure one resident was free from unwanted facial hair (Resident #22), failed to ensure one resident had clean hands and hair (Resident #32), failed to ensure one resident had clean hair and nails (Resident #62), and failed to ensure two residents had clean clothing to wear (Residents #62 and #71). The sample was 33. The census was 166. Review of the facility's nail care policy, dated 7/21/22, showed: -Policy: The purpose of nail care is to clean the nails, trim nails, and prevent infection; -Key points: Nails may be cleaned during bathing. Nail care includes daily cleaning and regular trimming. Review of the facility's ADL care bathing policy, dated 7/21/22, showed: -Policy: Nursing staff will assist in bathing residents to promote cleanliness and dignity; -Procedure: Assist resident with dressing/grooming as needed. 1. Review…

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, in two of two facility medication rooms and in two of three medication administration carts. The facility census was 166. Review of the facility's Medication Storage in the Facility policy, revised 11/2018, showed: -Medications and biologicals are stored safely, securely and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications; -All expired medications will be removed from the active supply and destroyed in the facility, regardless of the amount remaining. The medication will be destroyed in the usual manner. Observation of the 300 hall medication storage room on 1/23/25 at 10:10 A.M., showed a plastic bag containing nine ESwab Liquid collection and preservation kits (used to collect liquid samples for laboratory examination) expired as of…

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

Based on observation, interview and record review, the facility failed to ensure the kitchen floors, bulk bins, and appliances were free from food and trash debris. The facility failed to ensure the ceiling above a meal preparation station was free from dust build up, and failed to ensure the walk in- refrigerator and freezer floors were free from food and trash debris. The facility census was 166. Review of the facility's daily kitchen cleaning checklist, undated, showed: -Daily or after each use: all freezers and refrigerators are cleaned, floors swept and mopped daily. Review of the facility's weekly kitchen cleaning checklist, undated, showed: -Clean all freezers and refrigerators interior and exterior, deep clean oven, polish all stainless-steel surfaces, vents cleaned and free of dust, deep fryer cleaned and oil changed weekly. 1. Observation on 1/22/25, of the kitchen, showed: -At 9:25 A.M., the walk-in refrigerator had a pink liquid spill under the first rack and trash and food debris in various areas on the floor; -At 9:28 A.M., the walk-in freezer had trash and food debris…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents were treated with respect and dignity. One resident (Resident #214) required staff assistance with mobility and personal care needs. Staff left the resident's buttocks exposed while propelling the resident through common areas of the facility, and left the resident uncovered in bed with his/her genitals exposed and visible from the hallway outside of his/her room. Staff delivered a meal to the resident's room and failed to empty the resident's urinals, full of urine, leaving the urine in the resident's line of sight while he/she ate lunch. In addition, one employee made a video call on their personal cell phone while in a common area with one resident (Resident #22) in the background of the video. The sample was 33. The census was 166. Review of the facility's Resident Rights policy, last reviewed 4/26/23, showed: -Policy: The facility shall treat residents with kindness, respect, and dignity and ensure resident rights are…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents were appropriately assessed to self-administer medications, to obtain physician orders to self-administer medications, and to ensure staff adequately supervised residents during medication administration (Residents #20 and #214). The sample was 33. The census was 166. Review of the facility's Self-Administration of Medications policy, revised August 2014, 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 (IDT) 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; -Procedures include: -If the resident desires to self-administer medications, an assessment is conducted by the IDT of the resident's cognitive (including orientation to time), physical, and visual ability to carry out…

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 resident needs and preferences were accommodated for one resident (Resident #19) with communication and mobility impairments, when staff failed to ensure the resident's call light was within reach and when staff failed to transfer the resident back to bed, per the resident's request. The sample was 33. The census was 166. Review of the facility's Resident Rights policy, last reviewed 4/26/23, showed: -Policy: The facility shall treat residents with kindness, respect, and dignity and ensure resident rights are being followed; -Resident rights included exercise rights, planning and implementing care, making decisions/choices, and self-determination. Review of Resident #19's medical record, showed diagnoses included stroke, hemiplegia (paralysis to one side) affecting left nondominant side, acquired absence (amputation) of left leg above knee, aphasia (language impairment), frontal lobe and executive function deficit following cerebrovascular disease (conditions that affect blood flow to the brain), other…

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 records of residents' personal possessions for four residents (Resident #97, Resident #38, Resident #15 and Resident #265) The sample was 33. The census was 166. Review of the facility's admission agreement, revised June, 2023, showed: -Resident rights: -To keep and use your personal belongings and property as long as they don't interfere with the rights, health, or safety of others; -Personal items: -All personal property must be clearly and permanently labeled with the resident's name; -All food, liquids, medications, and personal effects brought to the resident must be brought to the nurses' station and checked with the nurse in charge before delivery to the resident; -The policy did not address how they would document and maintain personal property inventory sheets. 1. Review of Resident #97's medical record showed: -An admission date of 8/27/24; -A personal property inventory sheet, dated 8/28/24, showed: -No clothes, just 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 a significant change in status assessment was completed within 14 days after the determination was made a significant change occurred for one of one residents sampled for hospice (Resident #45). The facility identified three residents who received hospice services. The census was 166. Review of the facility's Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) policy, revised 4/26/23, showed: -Policy: The MDS is a standardized comprehensive assessment of all residents in Medicare or Medicaid certified facilities mandated by federal law to be completed and electronically transmitted to Centers for Medicare & Medicaid Services (CMS) in compliance with the guidelines in the MDS 3.0 Resident Assessment Instrument (RAI) User's Manual. Review of the resident's medical record, showed the resident was admitted to hospice on 5/15/24, with a primary diagnosis of cerebrovascular disease. Review of the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents received an accurate assessment, reflective of the residents' status at the time of assessment, by failing to identify one resident's (Resident #45) hospice status with life expectancy of less than six months, and one resident's (Resident #19) fall within the assessment review period. The sample was 33. The census was 166. Review of the facility's Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) policy, revised 4/26/23, showed: -Policy: The MDS is a standardized comprehensive assessment of all residents in Medicare or Medicaid certified facilities mandated by federal law to be completed and electronically transmitted to Centers for Medicare & Medicaid Services (CMS) in compliance with the guidelines in the MDS 3.0 Resident Assessment Instrument (RAI) User's Manual. 1. Review of Resident #45's medical record, showed: -admitted to hospice on 5/15/24 with primary diagnosis of cerebrovascular…

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 services provided met professional standards of practice by failing to transcribe two residents' (Residents #105 and #49) physician orders correctly to the Medication Administration Record (MAR). In addition, the facility administered medications to one resident (Resident #72) who did not have orders for crushed medications. The sample was 33 The census was 166. Review of the facility's Physician Orders policy, reviewed, 9/28/22, showed: -Purpose to provide guidance and ensure physician orders are transcribed and implemented in accordance with professional standards, state and federal guidelines; -Physician orders must be documented clearly in the medical record; The required components of a complete orders are: -Date and item of order; -Name of practitioner; -Name and strength of medication and treatment; -Quantity and duration; -Dosage and frequency; -Route of administration; -Indication or diagnosis; -Stop date if indicated;…

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 physician orders, the oxygen administration storage policy, and proper infection control techniques for two of 33 sampled residents (Resident #15 and #315). The census was 166. Review of the facility's Oxygen Administration and Storage policy, dated, 1/1/14, showed: -Purpose: To ensure staff follow safety guidelines and regulation for storage and use of oxygen; -Tubing: Oxygen tubing should be changed weekly; Nasal cannula (NC, tubing that delivers oxygen through the nose) tubing may need to be changed more frequently; -Pulse Oximetry: Residents who have oxygen order should have oxygen saturation levels measured by oximetry (a device that is placed on the finger and measures oxygen levels); The physician should be notified of any concern identified with oxygen titration needs so the physician may determine a need to change the order to best meet the resident's oxygen needs. Review of the facility's Physician Orders policy, reviewed…

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 acceptable infection control standards by not implementing Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) that employs targeted gown and glove use during high contact resident care activities) as recommended by the Centers for Disease Control and Prevention (CDC) and required by the Centers for Medicare and Medicaid Services (CMS) for residents with central lines to include dialysis (a treatment that helps remove waste products and excess fluid from the blood when the kidneys are not working properly) access sites, residents with gastrostomy tubes (g-tube, a tube that is surgically inserted into the abdomen and is used for liquid nutrition and medications) and wounds requiring treatments, for three residents (Resident # 97, #105, and #265) The sample was 33. The census was 166. Review of the facility's Enhanced Barrier Precautions (EBP), reviewed 5/15/24, showed: -Policy: The facility may expand the use 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 the deficiency cited at F567 under Event ID LQCK12. Based on interview and record review, the facility failed to receive authorization in writing to use personal funds of a resident that was discharged from the facility January 2024 with a credit in the amount of $772.00, until October 2024 when the resident was charged $875.00 after an updated bill was received from the resident's co-insurance. The facility failed to notify the resident and/or responsible party of additional charges and deducted $875.00, leaving the resident a balance owed in the amount of $103.00. The facility census was 166. Review of the facility's admission Agreement, showed: -We neither extend credit nor accept payment in installments. Unless otherwise stated, all payments required by this agreement are due and payable in full no later than the fifth of the month. All payments not paid when due shall be late payments and may be subjected to late payment charges of one percent per month. Payments properly made by you to use are not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY See the deficiency cited at F569 under Event ID LQCK12. Based on interview and record review, the facility failed to refund resident funds within 30 days of discharge for one resident reviewed (Resident #15). The resident was discharged from the facility January 2024 with a credit in the amount of $772.00. The facility failed to issue a refund after attempts to notify the corporate office to send a refund. The facility census was 166. Review of the facility's admission Agreement, showed: -We neither extend credit nor accept payment in installments. Unless otherwise stated, all payments required by this agreement are due and payable in full no later than the fifth of the month. All payments not paid when due shall be late payments and may be subjected to late payment charges of one percent per month. Payments properly made by you to use are not refundable except that, in the event of your death, transfer or discharge, we will refund the appropriate prorated portion of any advance payment. Any payment made by you…

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 the deficiency cited at F693 under Event ID LQCK12. Based on observation, interview and record review, facility staff failed to provide appropriate care and services to a resident with a gastrostomy tube (g-tube, a tube surgically placed into the stomach for administration of nutrition and medications) by failing to ensure the g-tube machine infused the correct amount of feeding formula and failed to turn off the g-tube machine at 8:00 A.M. as ordered on two of two days of observation. Resident #16. The sample was 14. The census was 166. Review of Resident #16's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/12/24, showed: -Severe cognitive impairment; -Diagnoses included cancer, high blood pressure, kidney failure, septicemia (blood poisoning), pneumonia, hyperlipidemia (high level of lipids in the blood), stroke, hemiplegia (paralysis on one side), malnutrition, and respiratory failure; -Has a feeding tube; -Proportion of total calories the resident received through parenteral or tube feeding: 51% 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 interview and record review, the facility failed to receive authorization in writing to use personal funds of a resident that was discharged from the facility January 2024 with a credit in the amount of $772.00, until October 2024 when the resident was charged $875.00 after an updated bill was received from the resident's co-insurance. The facility failed to notify the resident and/or responsible party of additional charges and deducted $875.00, leaving the resident a balance owed in the amount of $103.00. The facility census was 166. Review of the facility's admission Agreement, showed: -We neither extend credit nor accept payment in installments. Unless otherwise stated, all payments required by this agreement are due and payable in full no later than the fifth of the month. All payments not paid when due shall be late payments and may be subjected to late payment charges of one percent per month. Payments properly made by you to use are not refundable except that, in the event of your death, transfer…

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 refund resident funds within 30 days of discharge for one resident reviewed (Resident #15). The resident was discharged from the facility January 2024 with a credit in the amount of $772.00. The facility failed to issue a refund after attempts to notify the corporate office to send a refund. The facility census was 166. Review of the facility's admission Agreement, showed: -We neither extend credit nor accept payment in installments. Unless otherwise stated, all payments required by this agreement are due and payable in full no later than the fifth of the month. All payments not paid when due shall be late payments and may be subjected to late payment charges of one percent per month. Payments properly made by you to use are not refundable except that, in the event of your death, transfer or discharge, we will refund the appropriate prorated portion of any advance payment. Any payment made by you or on your behalf (for example, by an insurance company…

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

Based on observation, interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice for one resident (Resident #3) when the resident's medication and treatment orders were not reentered into the electronic medical record (EMR) until two days after the resident was readmitted to the facility from a hospital stay. The resident returned on 9/24/24 and the orders were entered on 9/26/24. The sample size was 10. The census was 166. Review of the facility's Physician 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 shall be provided by Licensed Practitioners authorized to prescribe orders; -Orders must be recorded in the medical record by the licensed nurse authorized to transcribe such orders; -Physician orders must be documented clearly in the medical record; -Physician orders that are missing required components, are…

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

Based on observation, interview and record review, facility staff failed to provide appropriate care and services to a resident with a gastrostomy tube (g-tube, a tube surgically placed into the stomach for administration of nutrition and medications) by failing to ensure the g-tube machine infused the correct amount of feeding formula and failed to turn off the g-tube machine at 8:00 A.M. as ordered on two of two days of observation. Resident #16. The sample was 14. The census was 166. Review of Resident #16's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/12/24, showed: -Severe cognitive impairment; -Diagnoses included cancer, high blood pressure, kidney failure, septicemia (blood poisoning), pneumonia, hyperlipidemia (high level of lipids in the blood), stroke, hemiplegia (paralysis on one side), malnutrition, and respiratory failure; -Has a feeding tube; -Proportion of total calories the resident received through parenteral or tube feeding: 51% or more; -Average fluid intake per day by intravenous (IV) or tube…

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 administer a medication prescribed for cancer treatment for one resident (Resident #5). The sample was six. The census was 177. Review of the facility's Medication Administration General Guideline, dated August 2014, showed the following: -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; -Procedures: -Administration 1. Medications are administered only by licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulations to administer medications; 2. Medications are administered in accordance with written orders of the prescriber. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to prevent significant medication errors when staff failed to ensure residents admitted to the facility received ordered medication timely (Residents #5, #8 and #9). The facility failed to administer medications that were available in the onsite medication administration machine and emergency kit. The census was 169. Review of the admission/readmission order policy, reviewed 9/27/23, showed: -Policy: upon admission/readmission, orders for care of the resident are received from attending physician, transcribed onto physician's orders and kept in the medical record; -Procedure: Admission/readmission orders are obtained on the day of admission in one of the following ways: -Physician provides written orders; -Nurse receives orders via telephone, in which case via telephone is indicated by nurse signature; -Orders are verified on the day of admission with the attending physician for accuracy and completeness prior to care rendered; -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 observation, interview and record review, the facility failed to protect the residents' right to retain and use personal possessions, including clothing, when personal clothing that was sent to laundry was not consistently returned and/or not returned timely for three residents investigated for missing clothing (Resident's #98, #70 and #56). Four of four linen rooms observed contained stacks of unlabeled resident clothing. In addition, seven of seven residents interviewed, who represented the resident counsel, reported concerns with personal clothing going missing. The census was 157. The sample was 31. Review of the facility's Inventory of Personal Items policy, dated 2/28/23, showed: -The facility will inventory the residents' personal items upon admission and discharge; -Personal items will be labeled with the residents' name on admission and thereafter when brought to the facility; -Responsibility: Nursing, social services, nursing administration, Director of Nursing (DON), and licensed nursing home…

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

Based on interview and record review, the facility failed to reconcile the petty cash (a small amount of cash that is kept in a facility's business office to dispense to residents who have a resident trust account) on a monthly basis. This practice potentially affected 97 residents who had resident trust accounts. The census was 157. Review of the facility's undated Resident Trust Fund policy, showed to assure the total balance of the Resident Trust Fund bank account and Resident Trust Cash Box reconciles with the totals of the Resident Fund Management Services (RFMS) resident accounts, RFMS will automatically reconcile these accounts every day. The Reconciliation Batch Report should be ran on a monthly basis. Any variances should be addressed and corrected immediately by the business office and/or the corporate office. Review of the monthly accounts for the months of May 2022 through April 2023, showed the absence of documentation of the ending balances for petty cash. Observation and interview on 5/24/23 at 10:52 A.M., showed Business Office Manager (BOM) R counted the petty cash…

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 and/or responsible parties were notified in a timely manner when a resident's account was within the $200 Social Security (SSI) limit ($5,301.85) or when the resident's account was over the SSI limit. This affected seven residents reviewed who received Medicaid benefits (Residents #101, #258, #108, #77, #68, #82 and #116). The census was 157. Review of the facility's undated Resident Trust Fund policy, showed a resident's combined personal accounts cannot exceed the amount determined by current state regulations. The Center shall issue a notice to the resident/legal guardian when the resident is within $200.00 of approaching this limit in the Resident Trust account. This report will be ran monthly and all residents within the designated limit shall receive notice that their funds are close to exceeding the state mandated personal allowance maximum limit. 1. Review of Resident #101's trust account, showed: -On 5/2/22, he/she had…

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 an adequate supply of linens, ensuring staff were able to provide care and residents were able to provide self care. Additionally the facility failed to maintain resident room floors and walls in good repair. This had the potential to affect all residents. The census was 157. 1. Observation on 5/22/23 at 12:10 P.M., on the 300 hall, showed limited inventory in the clean linen rooms and linen carts. 2. Observation on 5/22/23 at 1:41 P.M., on the 400 hall, showed limited inventory in the clean linen rooms and linen carts. 3. Observation on 5/22/23 at 2:04 P.M., on the 200 hall, showed limited inventory in the clean linen rooms and linen carts. 4. Observation on 5/22/23 at 2:09 P.M., on the 100 hall, showed limited inventory in the clean linen rooms and linen carts. 5. Review of Resident #91's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/14/22, showed the resident was 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, staff failed to provide care when requested by the resident, failed to ensure all urine was cleaned from a wheelchair prior to covering with a pad and placing the resident back into the wheelchair (Resident #86), and failed to provide the necessary care and services for residents who were unable to complete their own activities of daily living (ADL) for care, which included meal assistance and good personal hygiene (Residents #73, #139 and #56). The sample was 31. The census was 157. Review of the facility's ADL Care Bathing policy, dated 7/21/22, showed: -Nursing staff will assist in bathing residents to promote cleanliness and dignity. The charge nurse will be made aware of residents who refuse bathing; -Shower: Assist resident into the shower, encourage them to hold onto safety bars. Encourage resident to bathe him/herself and assist as needed. Assist with dressing/grooming as needed; -Bed bath: Allow resident to undress as much as they are able to do. Only…

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 facility policy for safe mechanical lift transfers, for two of two residents observed during mechanical lift transfers (Residents #86 and #99). The facility failed to have fully charged batteries to operate mechanical lifts. The facility also failed to secure an unlocked storage room, which contained a retractable utility knife. The sample was 31. The facility census was 157. Review of the facility's Sit to Stand Lift (mechanical lift) Transfer policy, dated 10/25/22, showed: -The facility may use a sit to stand lift for resident transfers with those who require assistance transferring from one surface to another to ensure safety; -Standing sling: -Position the sling around the back so it is two inches about the resident's waist with arms outside of the sling; -Place resident's feet on the base of the lift footrest; -Select the appropriate clip on the opposite end of the sling and connect; -Instruct the resident 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 observation, interview and record review, the facility failed to clean a sit to stand lift (mechanical lift) between resident use for two of two residents observed during mechanical lift transfers (Residents #86 and #99) and failed to clean a shower bed between resident use for one resident (Resident #73). Additionally, the facility failed to keep two out of four clean linen closets clean and organized . The sample was 31. The census was 157. Review of the facility's Standard Precautions policy, dated 10/25/22, showed: -The facility will use standard precautions which are the minimum infection prevention practices that apply to all resident care; -Handling soiled equipment: Equipment with blood, body fluid, secretions, and excretions in a manner that prevents mucus membrane exposure, contamination of clothing and transfer micro-organisms to others and the environment; -Environmental controls: Follow procedures for routine care, cleaning and disinfection of environmental surfaces, especially frequently…

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 ensure each resident receives an accurate assessment, reflective of the resident's status at the time of the assessment, for three residents. The sample was 31. The census was 157. 1. Review of Resident #91's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 3/24/23, showed: -Should brief interview for mental status (BIMS) be conducted: Yes; -BIMS assessment left blank; -Should resident mood interview be completed: Yes; -Mood interview left blank. During an interview on 5/23/23 at 1:52 P.M., MDS Coordinator B said the resident is alert and oriented, and the BIMS assessment should have been completed. 2. Review of Resident #86's physician orders, during the time frame of February 2023, showed no orders for anticoagulant medications. Review of the resident's annual MDS, dated [DATE], showed the resident received anticoagulant medications seven out of seven days. During an interview on 5/23/23 at…

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 document narcotic pain medication was administered on the Medication Administration Record (MAR) for one resident who received pain medication (Resident #73). In addition, the facility failed to ensure one resident received enteral feeding (a method of supplying nutrients directly into the gastrointestinal tract) at times specified by the physician (Resident #138). The sample size was 31. The census was 157. 1. Review of Resident #73's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/1/23, showed: -Moderate cognitive impairment; -Required extensive assist for bed mobility, dressing, toilet use and personal hygiene; -Always incontinent of bowel and bladder; -No behaviors; -Diagnoses included orthopedic conditions, diabetes, high blood pressure and depression. Review of the resident's care plan, undated and in use at the time of survey, showed: -Focus: The resident has chronic…

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 (Resident #99) with a pressure wound (skin or soft tissue injury that develops with prolonged periods of pressure over specific areas of the body) received necessary treatments and services to promote healing. The sample size was 31. The census was 157. Review of the facility's Wound Management policy, dated 11/15/22, showed: Policy: To promote wound healing of various types of wound, the facility will provide evidence-based treatments in accordance with current standards of practice and physician orders; Procedure: Wound Management: -Wound treatment will be provided in accordance with physician's order: -Cleansing method; -Type of dressing; -Frequency of dressing change; -The charge nurse will notify physician in the absence of treatment orders; -Dressing changes may be provided outside of the frequency parameter in certain situations: -Urine, stool or other bodily fluids have saturated through the dressing; -The dressing is dislodged; -The dressing is soiled. Review of Resident #99's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident received appropriate person-centered care to meet his/her highest practical psychosocial well-being when the facility failed to provide medically related social services and accurate social service evaluations for one sampled resident with a known history of depression (Resident #150). In addition, the facility failed to provide social services regularly for one resident (Resident #73). The sample size was 31. The census was 157. 1. During an interview on [DATE] at 8:44 A.M., the Social Services Director (SSD) said the facility did not have a policy on behavioral management. Review of Resident #150's medical record, showed; -admitted on [DATE]; -Diagnoses included major depressive disorder, colon cancer, dementia and insomnia. Review of the resident's Social Services Evaluation Admission, dated [DATE], showed: -Diagnoses included adjustment disorder with depressed mood; -Emergency contact information completed; -No…

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 document adequate indications and non-pharmacological interventions to support the use of haloperidol (an antipsychotic used to treat certain types of mental disorders) for one of five residents investigated for unnecessary medications (Resident #101). The census was 157. Review of the facility's Psychotropic Management Guidelines policy, revised September 2017, showed: -Purpose: A psychotropic drug is any drug which affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: anti-psychotic, anti-depressant, anti-anxiety, and hypnotic; -Based on the comprehensive assessment of the resident, the facility must ensure: -Residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; -Residents who use antipsychotic drugs…

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 that in accordance with accepted professional standards and practices, medical records are maintained that are complete and accurately documented for one resident observed after a fall when staff failed to document the fall timely or completely (Resident #61). The sample was 31. The census was 157. Review of the facility's Fall Management policy, dated 2/28/23, showed: -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 reduce injuries; -A fall is a sudden, uncontrolled, unintentional, downward displacement of the body to the ground or other objects, excluding falls resulting from violent blow or other purposeful actions; -Unwitnessed fall occurs when a resident is found on the floor and resident/employee is unaware of how he/she go…

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 repair the resident's headboard of the bed after he/she reported it was not in working order (Resident #6). The sample was 31. The census was 157. Review of Resident #6's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/18/23, showed: -Severely impaired cognition; -Diagnoses included coronary artery disease, aphasia (language disorder), dementia and depression; -Required extensive assistance with one person physical assist with bed mobility, dressing and hygiene; -Required extensive assistance with two or more person physical assist with toileting; -Required limited assistance with two or more person physical assist with transfers; -Bed rails not used. Review of the resident's care plan, updated 5/5/23, showed: -Focus: Resident has an Activity of Daily Living (ADL) self care performance deficit related to unspecified fracture of T 11-12 vertebrae (thoracic spinal cord); -Goal: Resident will remain current level of function in bed mobility,…

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 ensure each resident was afforded the right to manage his/her financial affairs, when the facility failed to advise residents of money held in the facility operating account that belonged to the resident. The facility failed to deposit funds, in excess of $100 for residents receiving Medicare and $50 for residents receiving Medicaid, in an interest bearing account that was separate from any of the facility's operating accounts, and credit all interest earned on resident's funds to that account. The deficient practice affected 71 residents (Residents #13, #38, #57, #68, #71, #80, #83, #113, #128, #154, #156, #168, #169, #170, #171, #172, #173, #174, #175, #176, #177, #178, #179, #180, #181, #182, #183, #184, #185, #186, #187, #188, #189, #190, #191, #192, #193, #194, #195, #196, #197, #198, #199, #200, #201, #202, #203, #204, #205, #206, #207, #208, #209, #210, #211, #212, #213, #214, #215, #216, #217, #218, #219, #220, #221, #222, #223, #224, #225, #226 and #227). Also, the facility failed to provide the Social Security…

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 provide Medicaid spend down letters when the balance of the resident's trust fund account exceeded $2,800.00. This deficient practice affected four residents (Residents #77, #84, #107 and #122). Additionally, the facility failed to provide a final accounting of individual resident trust fund balances within 30 days to the individual or probate jurisdiction administering the resident's estate for two residents (Residents #156 and #157). The facility census was 177. 1. Record review of the facility's maintained Resident Trust Fund Account for the period [DATE] through [DATE], showed the facility unable to provide documentation showing SSI resource limit letters were provided to residents, their designee, guardian and/or conservator when the resident trust fund account reached a balance of $2,800.00 or $200.00 from the SSI resources limit of $3,000.00. Record review on [DATE] of the Resident Trust Fund Accounts of Residents #77, #84, #107 and #122, showed…

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

Based on observation and interview, the facility failed to ensure residents who live on the 100, 200 and 400 halls could exercise their right to private communication when they failed to replace the resident telephones in a timely manner. The facility census was 177. 1. During an interview on 5/16/19 7:22 A.M., Resident #42 said he/she could not make a private phone call. There used to be cordless phones at the nurse's stations, but since the facility rewired the phone system about three months ago, they took the cordless phones away and never replaced them. If he/she wanted to make a call, he/ she had to ask the nurse to dial and then could only go as far away as the cord would stretch. There were always staff and other residents around. He/she felt bad about tying up the phone because the nurse needed to use it too. 2. During an interview on 5/16/19 at 7:26 A.M., Nurse U, who worked regularly on the 100 Hall, said residents could use the desk phone or the cordless phone . Residents could take the cordless phone to their room to use. Nurse U was unable to locate the cordless phone.…

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 develop and implement person-centered comprehensive care plans to meet preferences and goals and address residents' medical, physical, mental and psychosocial needs, by not including depression, pressure ulcers, oxygen use, activities, restorative therapy, pain, contractures, paralysis and edema on the care plans, for eight of 35 sampled residents (Residents #23, #151, #88, #49, #25, #28, #44 and #77). The census was 177. 1. Review of Resident #23's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/17/19, showed the following: -No cognitive impairment; -Total dependence on staff for activities of daily living; -Upper and lower extremity impairment; -Incontinent; -No antidepressant medication administered in past 7 days; -Diagnoses included high blood pressure, diabetes, anxiety, depression and chronic obstructive pulmonary disease (COPD-difficulty breathing). 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 ensure resident care plans reflected current needs by not updating them to include psychotic medication use and interventions, failed to reflect lower leg edema (swelling) and lower leg wraps, specific and current wound treatments, failed to reflect the change in wound treatments used and reflect the long term use of antibiotic as a prophylaxis. The affected five of 35 sampled residents (Residents #8, #144, #60, #56 and #47). The census was 177. 1. Review of Resident #8's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/1/19, showed the following: -Cognitively intact; -No mood issues; -Verbal behaviors daily; -Daily antipsychotic medication; -Diagnosis of depression. Review of the electronic physician order sheet (ePOS), showed an order, dated 3/21/19, for Seroquel (antipsychotic, used to treat treat certain mental and mood conditions) 50 milligrams (mg) for unspecified…

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 administer treatments as ordered (Residents #81, #51 and #5), failed to obtain orders for a peripherally inserted central catheter (PICC, a thin, soft, long catheter (tube) that is inserted into a vein. The tip of the catheter is positioned in a large vein that carries blood into the heart and used to administer medication), code status and inflatable boots (Residents #43, #44 and 56), failed to provide dietary supplements as ordered (Residents #23 and #154), failed to clarify orders (Resident #94) and failed to apply medical stockings as ordered (Residents #77 and #152). The census was 177. 1. Review of Resident #81's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/22/19, showed the following: -Severe cognitive impairment; -Limited staff assistance needed with hygiene; -Diagnoses of cancer, dementia and seizures; -Surgical wound treatment; -Received ointments other than 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 provide and ensure appropriate perineal (peri-care, cleansing the front of the hips, between the legs and buttocks) care to two of three perineal care observations (Residents #77 and #152). The facility also failed to provide meal service set up to one of 35 sampled residents (Resident #58). The census was 177. 1. Review of Resident #77's annual Minimum Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/23/19, showed the following: -Moderate cognitive impairment; -Extensive assistance required for all personal care and mobility; -Frequently incontinent of bowel and bladder; -Diagnoses included stroke and dementia. Observation on 5/15/19 at 9:03 A.M., showed Certified Nurse Aide (CNA) A entered the resident's room, washed hands and donned gloves. He/she removed the wet with urine brief, applied soap to a wet cloth and cleansed the genital area. He/she did not cleanse the urinary meatus and did not…

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

Based on interview and record review, the facility failed to ensure each nurse aide had no less than 12 hours of in-service education per year, based on their individual performance review, calculated by their employment date rather than the calendar year. The facility failed to ensure three of eleven randomly selected certified nurse aides (CNAs), employed by the facility over one year, received the required annual 12-hour resident care training. The census was 177. Review of the CNA individual service records, showed the following: -CNA M hired 8/24/2009, received eight and one half hours of in-service education; -CNA N hired 5/17/2010, received nine and one half hours of in-service education; -CNA O hired 6/5/2007, received eight hours of in-service education. During an interview on 5/17/19 at 10:30 A.M., the Director of Nursing said she was aware of the need for CNAs to receive 12 hours of resident-centered care inservicing every year.

Based on interview and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation. The facility failed to properly document narcotic counts for the controlled substances for four of the four facility medication carts. The facility census was 177. 1. Review of the 100 wing controlled substance shift change count sheet (three shifts: days, evening and nights), dated May 2019, showed the following: -On 5/1/19: Three packages of narcotics at 7:00 A.M. -No nurse signatures for the 7:00 A.M. on-coming shift; -No nurse signature or narcotic package counts for the 3:00 P.M. on-coming or off- going shift; -Three narcotic packages and no nurse signature noted for the 11:00 P.M. off-going shift; -On 5/2/19: Three packages of narcotics at 7:00 A.M.; -No on-coming nurse signature at 7:00 A.M.; -No total narcotic package count or on-coming and off-going nurse signature for 3:00 P.M.; -Three narcotic packages and no off-going or on-coming nurse signature for 11:00 P.M.; -On 5/3/19:…

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 record review and interview, the facility failed to attempt a gradual dose reduction (GDR) for a psychotropic medication for one resident (Resident #41) and failed to obtain a new order, or discontinue the use of an as needed (PRN) psychotropic drug beyond the 14 day limit for one resident (Resident #144). The sample size was 35. The facility census was 177. 1. Review of Resident #41's electronic physician order sheet (ePOS), showed an order dated 9/15/18 for quetiapine fumarate (Seroquel, an antipsychotic used for major behavior disorders) 25 milligrams (mg) take one tablet daily at bedtime for major depressive disorder. No reduction of the medication was indicated in the POS since 9/15/18. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/27/19, showed the following: -Moderate cognitive impairment; -No mood or behaviors; -Received hospice services; -Diagnoses of dementia without behavior disturbance, seizure…

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 date insulin flex pens (prefilled insulin pens) once opened, discard outdated insulin pens and ensure the resident's name appeared on the medication for 10 of 30 insulin pens and vials observed on two of two medication carts. The census was 177. 1. Observation on [DATE] at 9:04 A.M., of the medication cart on 100 hall, showed the following: -A total of 18 flex-pens and two vials of insulin opened and in use; -One Humalog (fast acting) insulin flex-pen, opened and dated [DATE]; -One Humalog insulin flex-pen opened and dated [DATE]; -One Humalog flex-pen, opened and dated [DATE]; -Four Novolog (short acting insulin) flex-pens with no date opened or date expired; -One Lantus (long acting insulin) flex-pen in use with no resident name; -One Humalog flex-pen opened with no date opened or expired. During an interview on [DATE] at approximately 9:15 A.M., Licensed Practical Nurse (LPN) S said that all flex-pens and vials should be dated and labeled 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.

Based on observation and interview, the facility failed to ensure food was stored and served in a manner to prevent contamination by not covering desserts or the clean mixer bowl after use, and serving oatmeal from a cart, table to table in the dining room, from an uncovered pan. This deficient practice had the potential to affect all residents who ate at the facility. The census was 177. 1. Observation of the kitchen showed the following: -On 5/13/19 at 9:17 A.M. and 5/14/19 at 11:44 A.M., a sign on the wall behind the stand mixer read clean mixer and slicer after use and cover. The mixer bowl sat underneath the sign next to the mixer uncovered; -On 5/14/19 at 11:24 A.M., a cart sat in front of the steam table and held three trays of peach cobbler dessert cups. The top tray held five covered dessert cups, middle tray held approximately 34 covered dessert cups and the bottom tray held 34 uncovered dessert cups. The cart sat in the kitchen uncovered until meal service began at approximately 12:00 P.M. 2. Observation of the dining room on 5/17/19 at approximately 7:30 A.M. and 7:50…

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 and collaborate care with resident elected hospice providers and failed to obtain a physician's order for hospice services. The facility showed 19 residents elected hospice services and four of those were included in the sample. Problems with coordinated plans of care were found with four of four residents reviewed for hospice services (Residents #151, #41, #85 and #43). The census was 177. 1. Review of Resident #151's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/26/19, showed the following: -Moderate cognitive impairment; -Required extensive assistance from staff for activities of daily living such as transfers and dressing and limited assistance for personal hygiene and toileting; -Diagnoses included cachexia (A general state of ill health involving marked weight loss and muscle loss), glaucoma and anemia; -Special treatments received while a resident: Hospice. Review of the…

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

Based on observation, interview and record review, the facility failed to maintain appropriate infection control by ensuring staff handled medications to prevent the potential spread of infection during medication administration by staff who used bare hands to administer medications to one resident (Resident #81) and failed to sanitize hands during medication administration for two of four observations and failed to handle soiled linen appropriately. The census was 177. 1. During an observation and interview on 5/14/19 at 8:20 AM, Certified Medication Technician (CMT) Q prepared to administer morning medications to Resident #81. He/she dispensed medications into a medication cup. One tablet dropped from the medication card and fell onto the top of the medication cart next to the plastic medication cup. CMT Q used his/her bare hand, picked up the tablet and placed the tablet into the medication cup with the other ordered medications. He/she gave the medications to the resident. CMT Q observed the resident take the medications, and he/she returned to the medication cart, initialed 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 safe transfer techniques for two of three observed resident transfers. This practice placed the residents at risk for falls or injuries during transfers. This affected one expanded sample resident (Resident #112) and one of 35 sampled residents (Resident #152). The census was 177. 1. Review of Resident #112's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/9/19, showed the following: -admitted on [DATE]; -Moderate cognitive impairment; -Total assistance of two staff with all transfers; -Not steady during transfers without staff assistance; -Received hospice services; -Diagnoses of vascular disease, lung disease and schizophrenia. Review of the admission care plan, dated 4/9/19, showed no transfer status. Review of the hospice coordinated care plan, dated 3/3/19, showed the resident needed total assistance with all transfers. During an observation and interview 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 observation, interview and record review, the facility failed to maintain proper placement and privacy of one resident's (Resident #59's) indwelling urinary catheter (a tube inserted into the bladder for purpose of continual urine drainage) and two supra pubic (SP, a small rubber tube inserted through the lower abdomen in to the bladder to drain urine) catheters for two residents (Residents #94 and #154). Staff allowed the urinary drainage bags to rest on the floor, staff did not intervene when there were kinks in the tubing preventing proper drainage and staff did not cover a drainage bag with a privacy cover. The facility identified six residents as having urinary catheters and of those six, problems were found with three. The sample size was 35. The census was 177. 1. Review of Resident #59's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/9/19, showed the following: -Severe cognitive impairment; -Dependent on staff for all personal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility staff failed to adequately assess pain, record the degree and location of pain, re-evaluate the effectiveness of pain medication, notify the physician of ineffective pain control and failed to follow a physician's order for pain medication administration, all which allowed for unnecessary discomfort. This practice affected two residents (Resident's #80 and #88). The sample size was 35. The census was 177. 1. Review of Resident #80's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/20/19, showed the following: -admitted to the facility on [DATE]; -No cognitive impairment; -Extensive assistance required by staff for all personal care and mobility; -Frequent severe pain that limits day to day activities; -Diagnoses included malnutrition, chronic low back pain, spinal stenosis (narrowing of the small spinal canal, which contains the nerve roots and spinal cord causing pinching of the spinal…

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 thorough assessments, monitoring and ongoing communication with the dialysis center for a resident who received dialysis (process for removal of waste and excess water from the blood due to kidney failure). The facility identified four residents who received dialysis. Of those four, two were selected for sample and issues were found with one resident (Resident #88). The sample size was 35. The census was 177. Review of Resident #88's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/27/19, showed the following: -An admission date of 3/14/19; -Cognitively intact; -Required extensive staff assistance with transfers, mobility, hygiene, dressing and toileting; -Diagnoses included cancer, heart failure, diabetes, end stage renal disease, arthritis and chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe); -Special treatments received while a resident: Dialysis Review of the resident's…

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