Stonebridge Florissant

Based on interview and record review, the facility failed to provide eight hours of Registered Nurse (RN) coverage on 18 out of 38 days reviewed for staffing. This had the potential to cause unmet health needs for all residents. The census was 85. Review of the Nursing Services and Sufficient Staff Policy, dated revised 1/31/23, showed: -Except when waived, the facility must use the services of a Registered Nurse for at least 8 consecutive hours a day, 7 days a week. Review of the facility's daily staffing patterns, dated 1/22/24 through 2/28/24, showed: -On 1/22/24, 1/23/24, 1/26/24, 1/27/24, 1/28/24, 1/30/24, 2/2/24, 2/6/24, 2/9/24, 2/10/24, 2/11/24, 2/13/24, 2/16/24, 2/20/24, 2/23/24, 2/24/24, 2/25/24 and 2/27/24, there was no RN coverage. During an interview on 2/27/24 at approximately at 9:30 A.M., the scheduler said the facility had one RN and when he/she was off, the Director of Nursing or the Minimum Data Set (MDS) Nurse would cover. During an interview on 2/27/24 at 1:03 P.M., the Administrator said the facility had one RN and, in their absence, the facility did not have an…

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

Based on interview and record review, the facility failed to develop and implement a water management program to reduce the growth/spread of Legionella (a bacterium that can live and grow in water systems and causes Legionnaires Disease (a severe form of pneumonia caused by Legionella bacteria)) and other opportunistic pathogens in the building's water system. This failure had the potential to affect all residents who reside in the facility. The sample was 24. The census was 85. Review of the facility's Water Management Policy, dated September 2022, showed: -Policy: It is the policy of this facility to establish water management plans for reducing the risk of Legionellosis and other opportunistic pathogens in the facility's water systems based on nationally accepted standards; -Definitions: - Legionellosis refers to two clinically and epidemiologically distinct illnesses: Legionnaires' disease, which is typically characterized by fever, myalgia (muscle aches and pain), cough, and clinical or radiographic pneumonia; and Pontiac fever (a mild flu-like illness caused by exposure 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 provide a comfortable and homelike environment for residents when staff failed to ensure common areas were free from strong urine odors that did not dissipate throughout the investigative process. The census was 85. Review of the facility's Facility Responsibilities Policy, dated September 2022, showed: -Safe Environment. The resident has a right to a safe, clean, comfortable, and homelike environment; -The facility will provide: a safe, clean, comfortable, and homelike environment, allowing the resident to use his/her personal belonging to the extent possible; -Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Observation on 2/22/24 at 8:35 A.M. and at 9:44 A.M., showed a large yellow soiled utility bin outside of room [ROOM NUMBER]. A strong smell of urine was present in the hallway from room [ROOM NUMBER] to the nurse's station, outside of room [ROOM NUMBER]. Observation 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 ensure residents who required assistance with activities of daily living (ADLs) received personal hygiene assistance in accordance with their personal needs when one resident was observed with a soiled brief for an extended amount of time (Resident #46). In addition, the facility failed to provide showers for two residents (Residents #20 and #41) and failed to properly wash one resident's dentures (Resident #29). The sample size was 24. The census was 85. Review of the facility's ADL Care of the Resident Policy, revised December 2018, showed: -It is the policy of this facility to provide ADL care to residents to ensure needs are met daily; -Policy Explanation and Compliance Guidelines: -Each resident's physical functioning will be assessed in accordance with the facility's assessment procedures; -The resident, to the extent possible, and/or the family/representative will be included in setting goals of care related to ADLs/physical…

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 appropriate and competent staffing to meet the needs of residents when call lights were not answered in a timely manner for residents, including Resident #46 and #41. The sample size was 24. The census was 85. Review of the facility's Nursing Services and Sufficient Staff Policy, dated revised 1/31/23, showed: -The facility will supply services by sufficient numbers of each of the following personnel types on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans; -Providing care includes, but is not limited to, assessing, evaluating, planning, and implementing resident care plans and responding to resident's needs. Review of the facility's Facility Assessment, updated 1/19/24, showed: -The facility had two nursing units, an East and [NAME] wing; -Based on the current population as of 1/31/24, showed: -Bathing: 67 residents needed assistance of 1-2 staff and 13 were dependent; -Dressing: 57…

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

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored per acceptable standards of practice. The facility identified eight medication/treatment carts and two medication rooms. Four of the eight carts and one medication room were checked for medication storage. Issues were found in one medication room, two medication carts and one treatment cart. Staff failed to date an opened vial of tuberculin purified protein derivative (PPD, used to diagnose silent (latent) tuberculosis (TB) infection) solution, artificial tears (eye drops used to lubricate dry eyes and help keep moisture on the outer surface of eyes), and Miralax polyethylene glycol powder (used as a laxative to treat occasional constipation or irregular bowel movements). In addition, the staff failed to keep one treatment cart clean from spilled iodine solution (antiseptic for minor cuts and abrasions). The census was 85. Review of the facility's Storage of Medication Policy, revised 7/10/22, showed: -Policy: Medications and biologicals are stored safely,…

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 explicitly inform the resident or his or her representative of their right not to sign an arbitration agreement (a private process where disputing parties agree that one or several other individuals can make a decision about the dispute after receiving evidence and hearing arguments) as a condition of admission, or as a requirement to continue to receive care at the facility, for three of 25 sampled residents (Residents #87, #82 and #26). The census was 85. Review of the facility's Arbitration Agreements Policy, dated September 2022, showed: -Policy: This facility asks all residents to enter into an agreement for binding arbitration. We do not require binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, this facility; -Definition: -Arbitration is a private process where disputing parties agree that one or several other individuals can make a decision about the dispute after receiving evidence 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 staff completed routine inspections of bed frames, mattresses and bed/side rails as a part of a regular maintenance program to identify areas of possible entrapment for four of 24 sampled residents (Residents #29, #61, #20 and #41). The census was 85. Review of the facility Proper use of Side Rails Policy, dated September 2022, showed; -Statement: It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. If bed rails are used, the facility ensures correct installation, use, and maintenance of the rails; -Definitions: -Bed Rails are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one-half, one-quarter, or one-eighth lengths. Also, some bed rails are not designed as part of the bed by the manufacturer…

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 uphold one resident's rights (Resident #46) by turning off the resident's call light without providing assistance to the resident or notifying staff the resident needed assistance, resulting in the resident having to wait an extended amount of time before staff provided assistance. In addition, the facility failed to ensure a resident was treated with dignity when a staff member interacted inappropriately with a resident who required assistance with his/her clothing (Resident #40). The sample size was 24. The census was 85. Review of the facility's Resident Right's policy, dated September 2022, showed: -Policy: The facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all the rules and regulations governing resident conduct and responsibilities during the stay in the facility; -Resident Rights: The resident has the right to a dignified existence,…

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 three of 24 sampled residents (Residents #29, #26 and #41). The census was 85. Review of the facility Care Planning - Interdisciplinary Team Policy, revised [DATE], showed: -Policy: Our facility's care planning/interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident; -A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff); -The policy failed to show when a care plan should be updated and failed to show who was responsible for updating the care plan. 1. Review of Resident #29's annual MDS, dated [DATE], showed: -Cognitively impaired; -Activities of daily living (ADL), chair/bed 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.

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 using an unsafe technique (Resident #17). The census was 85. Review of the facility's Mechanical Lifting Machine Policy and Procedure, revised July 2017, showed: -The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instructions; -At least two nursing assistants are needed to safely move a resident with a mechanical lift; -Mechanical lifts may be used for tasks that require: -Lifting a resident from the floor; -Transferring a resident from bed to chair; -Lateral transfers; d- Lifting limbs; -Toileting or bathing; -Repositioning; -Types of lifts that may be available in the facility are: -Floor-based full body sling lifts; -Overhead full body sling lifts; and -Sit-to-stand lifts. -Lift design and operation vary across manufacturers. Staff must be trained and demonstrate competency using…

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 #83), who received tube feeding (supplies liquid nutrition) through a gastronomy tube (g-tube, a tube that is placed directly into the stomach through an abdominal wall incision for the administration of food, fluids and medicine) received the appropriate treatment and services when staff failed to keep the resident's head elevated while tube feeding formula infused and provided care with the resident laying flat while tube feeding formula infused. The sample size was 24. The census was 85. Review of the facility's Enteral Nutrition policy, revised January 2014, showed: -Policy Statement: Adequate nutritional support through enteral feeding will be provided to residents as ordered; -Policy Interpretation and Implementation; -The interdisciplinary team, including the Dietician, will conduct a full nutritional assessment within current initial assessment timeframes to determine the clinical necessity of enteral feedings. The assessment will include; -Evaluation 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.

Based on interview and record review, the facility failed to obtain a stop date of 14 days or less on an as needed (PRN) psychotropic medication (a chemical substance that changes brain function and results in an alteration in perception, mood, consciousness or behavior) for one resident (Resident #84). The sample size was 24. The census was 85. Review of the facility's Use of PRN Psychotropic Drugs policy, dated October 2017, showed: -Policy Statement: Resident's drug regiment will be free from unnecessary drugs, including unnecessary psychotropic drugs; -PRN orders for psychotropic drugs are limited to 14 days, except as provided if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days. He or she should document their rationale in the resident's medical record and indicate the duration for the PRN order; -PRN orders for psychotropic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that in accordance with accepted professional standards and practices, medical records are maintained that are complete and accurately documented for two residents (Residents #84 and #59). The sample was 24. The census was 85. The facility did not provide a policy for transcribing physician's orders, as requested. 1. Review of Resident #84's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 11/23/23, showed: -Should brief interview for mental status be conducted? No (resident rarely/never understood); -Diagnoses included: anemia (low red cell count), high blood pressure, diabetes, and dementia; -Received hospice care; -Pain frequency: occasionally. Review of the physician order sheet, in use at the time of survey, showed: -An order for: 9/20/2023 Morphine Sulfate Solution (pain medication) 20 mg/5 mL, give 0.25 ml by mouth every 4 hours as needed for shortness of…

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

Based on interview and record review, the facility failed to ensure a resident who was admitted with a Foley (brand name) catheter (a hollow tube inserted into the bladder, used to drain urine from the body) for diagnosed bladder disease received catheter care per standards of practice. The facility did not document catheter output. The resident experienced a change in condition, was sent to the hospital, where hospital staff drained purulent and foul smelling urine from the resident's bladder (Resident #1). This affected one out of two residents the facility identified as using catheters. The census was 85. Review of the urinary catheter care policy, undated, showed: -Purpose: to prevent catheter associated urinary tract infections (UTI); -General guidelines: -Input/output: observe the resident's urine level for noticeable increases or decreased. If the level stays the same, or increases rapidly, report it to the physician or supervisor. Maintain an accurate record of the resident's daily output per the policy. Review of Resident #1's medical record, showed: -re-admitted :…

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 could safely administer their own medications for three of three residents observed with medications or treatments in their room or left at their side (Residents #34, #10 and #308). The census was 81. Review of the facility's Self-Administration policy, revised December 2016, showed: -Policy Statement: -Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so; -Policy Interpretation and Implementation: -As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident; -If the resident is able and willing to take responsibility for documenting their self-administration of medications, the resident will be instructed on how to complete a record indicating 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 residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for two residents (Residents #11 and #6). The facility failed to develop resident care policies for restorative services, based on professional standards of practice, including who may provide specific treatments. The facility identified 23 residents as having contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). The sample was 19. The census was 81. 1. Review of the Department of Health and Senior Services, Centers for Medicare and Medicaid Services Resident Census and Condition of Residents form CMA-672, completed by the facility staff and dated 5/17/21, showed: -Mobility: Residents with contractures: 23; -Of the total number of residents with contractures, how many had a contracture(s) on admission: 23. On 5/21/21 at 9:39…

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 there would be a correct emergency response for one resident (Resident #29), to comply with an order for do not resuscitate (DNR, instructions to health care providers not to do cardiopulmonary resuscitation (CPR) if the heart and respirations stop) due to having two active and opposing code statuses, DNR and full code. The sample was 19. The census was 81. Review of the facility's Do Not Resuscitate Order policy, dated February 2014, showed our facility will not use CPR and related emergency measures to maintain life functions on a resident when there is a DNR order in effect. Review of Resident #29's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 11 out of a possible score of 15. A BIMS score of 8-12, showed moderately impaired cognition. Review of Resident #29's electronic medical record, reviewed on [DATE], showed: -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 notify one resident's representative (Resident #43) regarding a change in condition, which required placing the resident on suicide watch. The sample size was 19. The census was 81. Review of the facility's Change in a Resident's Condition or Status policy, revised November 2019, showed the following; -Policy Statement: -Our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (examples given, changes in level of care, billing/payments, residents rights, etc.); -Policy Interpretations and Implementations: -The Nurse Supervisor/Charge Nurse will notify the resident's attending physician or on-call physician when there has been: -A significant change in the resident's physical/emotional/mental condition; -Unless otherwise instructed by the resident, the Nurse Supervisor/Charge Nurse will notify the resident's family or representative…

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 respect residents' right to personal privacy during personal care for two of six residents observed during personal care (Residents #207 and #448). Staff left one resident's genitals exposed to the roommate during care when they failed to pull the privacy curtain completely around the bed and exposed a resident's chest to an open window as a car was observed to pull into the facility parking lot. The sample was 19. Census was 81. Review of the facility's untitled and undated policy, provided by the facility as the perineal care (cleansing of the surface area between the thighs, extending from the pubic bone to the tail bone) policy, showed: -Purpose: To provided cleanliness and comfort to the resident, aid in the prevention of skin irritations, infection and to observe the resident's skin condition; -Close the door and pull the privacy curtain. Review of the facility's Resident Rights, provided to the residents upon admission and available…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized care plans, to address the specific needs of the residents regarding wounds, transfer status, Activities of Daily Living (ADLs), incontinence, colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall) care, emergency code status, oxygen use, weight loss, dietary needs, hospice services and falls for 11 residents (Residents #100 #101, #207, #348 , #349, #27, #39, #10, #249, #400 and #405). The sample was 19. The census was 81. Review of the facility's Care Plans, Comprehensive Person-Centered policy, revised on 12/2016, showed: -Policy statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; -Policy interpretation and implementation: -The interdisciplinary team (IDT) is 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 ensure care and services were provided according to acceptable standards of clinical practice. The facility failed to ensure treatment orders were transcribed correctly and followed as ordered for one resident (Resident #27). Staff also failed to follow physician orders for physician follow up, diet orders and application of heel protectors (Residents #200, #250 and #100). In addition, facility staff failed to accurately assess the access site for one resident (Resident #250), clarify diet orders and obtain an admission weight (Residents #249 and #251). The sample was 19 and the census was 81. 1. Review of Resident #27's most recent quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 12/9/20, showed: -Cognitively intact; -Independent with activities of daily living (self-care activities); -Diagnoses included high blood pressure, diabetes, anxiety, depression, bipolar, venous insufficiency…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow appropriate discharge procedures and complete discharge and/or transfer documentation. This affected three of three reviewed closed records (Residents #1, #9 and #398). The sample was 19. The census was 81. Review of the facility's Transfer and Discharge Policy dated revised November 2019, showed no mention of discharge summaries, recapitulation of the resident's stay, final summary of the resident's status and reconciliation of pre- and post-discharge medications. 1. Review of Resident #1's closed record, showed the following: -admitted on [DATE], and readmitted on [DATE]; -discharged to hospital emergency room on 3/10/21; -Diagnoses included Bipolar disorder, epilepsy and depression. Review of the resident's nursing note dated 3/10/21, showed: -Resident will be sent out to hospital for a psych evaluation and treatment due to explosive behavior towards another resident; -Resident is agreeable to go; -Ambulance called for pick-up and ER called…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy and monitor and reassess for further decline for two residents (Residents #400 and #401) that were experiencing a significant change in condition out of 19 sampled residents. The census was 81. Review of the facility's Change in Resident's Condition or Status Policy, revised [DATE], showed: -Policy statement: -- Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.); - Policy Interpretation and Implementation; --The nurse will notify the resident's Attending Physician or physician on call when there has been a: --significant change in the resident's physical/emotional/mental condition; --need to alter the resident's medical treatment significantly; --refusal of treatment or medications two (2) or more consecutive times); --need to 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.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 29 opportunities observed, four errors occurred, resulting in a 13.79% error rate (Resident #301). The sample was 19. The census was 81. Review of the facility's Administering Medications through an Enteral Tube policy, revised on 12/2012, showed: -Purpose statement included: -To provide guidelines for the safe administration of medications through enteral tube; -Preparation included: -Verifying that there is a physician order for the procedure; -Reviewing the care plan to assess for special needs; -Assembling equipment and supplies; -General guidelines included: -Following the medication administration guidelines in the policy Administering Medications; -Requesting liquid forms of medications from the pharmacy; -Do not add medication directly to enteral feeding formula; -Do not mix medications together prior to administering them through an enteral tube and to administer each medication separately; -Check with the pharmacy and/or check the facility…

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

Based on observation, interview and record review, the facility failed to maintain medical records on each resident that are complete and accurately documented, for three residents (Residents #301, #27 and #10). The sample was 19. The census was 81. 1. Review of Resident #301's medical record, showed diagnoses included stroke, gastrostomy status (having a gastric tube (g-tube) a tube inserted into the stomach through the abdominal wall to provide food, nutrition and medications), heart disease, high blood pressure, dysphagia (difficulty swallowing), seizures, and dementia. Review of the resident's electronic physician order sheet (ePOS), showed: -An order, dated 2/26/21, for Norco (narcotic pain medication that contains hydrocodone and acetaminophen) 5-325 milligrams (mg) every four hours as needed per g-tube. Observation on 5/18/21 at 7:27 A.M., showed Licensed Practical Nurse (LPN) H administered the resident's routine medications. LPN H said the resident asked for an as needed pain pill, so he/she will administer a Norco tablet. LPN H obtained one Norco 5-325 mg tablet, crushed…

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 exercise standard infection control and prevention precautions while providing personal care to two of six residents (Residents #207 and #448). Staff did not perform appropriate hand hygiene and glove changes while providing personal care to both residents and used a soiled washcloth to wash multiple areas of the body. In addition, staff did not handle a visibly stool-soiled washcloth in a manner consistent with acceptable practices for Resident #207. The sample was 19. The census was 81. Review of an untitled and undated policy, provided by the facility as the perineal care (cleansing of the surface area between thighs, extending from the pubic bone to the tailbone) policy, showed: -Purpose: To provide cleanliness and comfort to the resident, aid in the prevention of skin irritations, infections and to observe the resident's skin condition. -Preparation included gathering: -A wash basin; -Towels; -Washcloths; -No rinse Peri-wash;…

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.