Meadow View Health & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain the floors free from a heavy buildup of dust and debris in the following resident rooms 208, 207, 302, 300, 601, 510, 500 Hall shower room, 607, 405, 410, 409, 407, 401; failed to maintain the fans free of a heavy buildup of dust in the following resident rooms 302, 301; and failed to maintain ceiling vents free of a heavy buildup of dust in the following resident rooms 405 and the 500 Hall shower room . This practice potentially affected at least 30 residents who resided in or used those areas. The facility census was 88 residents. 1. Review of the undated Housekeeping Route sheet (a sheet which showed the steps to clean the resident rooms), showed: 7-Step room cleaning: 1. Pull Trash. 2. Dust horizontal surfaces. 3. Sanitize high traffic areas. 4. Spot clean walls. 5. Sweep floors under and behind furniture and beds. 6. Damp mop floors under and behind furniture and beds. 7. Wipe down beds. 8. Sanitize high touch areas such as…

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 system in place for monitoring shower/bathing related to Activities of Daily Living (ADL's- grooming, bathing, hygiene), and to ensure baths or showers were provided at as scheduled for five sampled residents (Resident #6, #32, #58, #76, and #85) out of 18 sampled residents. The facility census was 88 residents. Review of undated facility policy entitled Bath, Shower/tub showed: -The purpose was to promote cleanliness, provide comfort to the resident and observe the condition of the resident's skin. -Complete bathing per residence preference (shower or bath). -Document the time the shower/tub bath was performed. -Document the name and title of the individual(s) who assisted the resident with shower/tub bath. -Document all assessment data. -Document how the resident tolerated the shower /tub bath. -Document if the resident refused shower/tub bath, the reason(s) why and the interventions taken. -Document the signature and title 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 cook broccoli florets so they would not be mushy; failed to follow the recipe for pureed (cooked food, that has been ground, pressed, blended or sieved to the consistency of a creamy paste or liquid) broccoli, so the broccoli would be palatable; and failed to maintain room trays at the 600 Hall and the 300 Hall at or close to 120 ºF (degrees Fahrenheit) at the time of service. This practice potentially affected at least 13 residents. The facility census was 88 residents. 1. Review of the recipe for pureed broccoli florets, dated 9/1/15, showed: - Steam broccoli 15-25 minutes until tender. - Drain broccoli, in large mixing bowl, and toss broccoli with margarine and season with salt and pepper. - Transfer to service pans and hold at a temperature of 135 ºF or greater. - Puree step: Remove desired number of servings and add nutritive liquid such as milk or broth. Blend until desired consistency. - Add approved thickener to achieve desired…

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 ensure there was negative airflow in the restrooms of the following resident rooms: 106, 102, 210, 209, 206/204, 205, 311/309, and 302/304. This practice potentially affected at least 20 residents who resided in those rooms. The facility census was 88 residents. Note: Air flow was tested by holding one piece of tissue paper to the ceiling vent. If the paper was drawn up then negative air flow was present; if the paper was not drawn to the ceiling vent, then negative airflow was absent. 1. Observations with the Maintenance Director and the Regional Maintenance Person on 5/21/24, showed: -At 9:52 A.M., there was not any negative airflow from the restroom vent of resident room [ROOM NUMBER]. -At 9:57 A.M., there was not any negative airflow from the restroom vent of resident room [ROOM NUMBER]. -At 10:04 A.M., there was not any negative airflow from the restroom of resident room [ROOM NUMBER]. -At 10:11 A.M., there was not any negative airflow from 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 obtain a physician order for the setting of the low air loss mattress (LAL - a mattress designed to distribute weight over a broad surface and help prevent skin breakdown. It has continuous air flow through tiny holes on the mattress surface) for one sampled resident (Resident #77) who had developed a Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. It may also present as an intact or open/ruptured blister) out of 18 sampled residents. The facility resident census was 88 residents. Review of the facility's Pressure Ulcer (PU)/Skin Breakdown - Clinical Protocol policy, revised April, 2018 showed the physician will order pertinent treatments, including pressure reduction surfaces and identify medical interventions related to wound management. 1. Review of Resident #77's admission Record showed the resident was readmitted to the facility on [DATE] with…

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 accurate documentation of refusal of enteral feeding via feeding tube called Percutaneous endoscopic gastrostomy (is a surgery to place a feeding tube also called a PEG or G-tube) and physician order for total amount caloric formula to be given in a 24 hour period, for one sampled resident (Resident #4) who's at risk for weight loss due to decline health, refusal of treatment and cares out of 18 sampled residents. The facility resident census of 88 residents. Review of the facility Policy for Medication Orders revised on 11/2014 showed: -Enteral feedings orders: when recording orders for enteral tube feedings, specify the type of feeding, amount, frequencies of the feeding and rationale if as needed. -The order should always specify the amount of flushing following the feeding. Review of the facility Enteral Tube feeding via a Pump revised on 11/2018 showed: -Document the average fluid intake per day. -If the resident refused…

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 puree (to make food into a paste or a thick liquid suspension which is made from finely ground cooked food) turkey into a smooth texture that was not stringy. This practice potentially affected three residents with pureed diets. The facility census was 88 residents. 1. Review of the recipe for pureed turkey showed: - Place turkey roasts in oven at a temperature of 375 ºF (degrees Fahrenheit) and roast for 3-4 hours. [NAME] until an internal temperature of 165 ºF was reached. - Remove from oven and allow turkey breast to rest for 15 minutes prior to carving. - Hold at 135 ºF or greater, for service. - For pureed step do the following: Remove the desired number of servings and add nutritive liquid such as milk, broth etc. Blend until desired consistency. Add approved thickener to achieve desired consistency if needed. Observation on 5/19/24 from 12:57 P.M. through 1:00 P.M., showed the following: - DC A did not have the recipe book open. - Dietary [NAME] (DC) A placed 3 servings of (3-4 ounces per serving) into…

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 promote and enhance one sampled resident's (Resident #2) feelings of self-worth and self-esteem, when Certified Nursing Assistant (CNA) A, was disrespectful and rude out of four sampled residents. The facility census was 93 residents. On 8/14/23, the Administrator was notified of the past noncompliance which occurred on 8/1/23. The facility administration was notified on the same day of the incident and the investigations were started. Facility staff were educated on Dignity, Respect, and Abuse policy, resident intervention and behaviors before the start of the next shift. Resident care plans were updated. The deficiency was corrected on 8/1/23. Review of the facility policy titled, Dignity, dated 2/2021 showed: -Each resident shall be cared for in a manner that promoted and enhanced his/her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. -Resident were treated with respect at all times. -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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to promote dignity and self-worth for three sampled residents (Resident #14, #44 and #81) out of 19 sampled residents. The facility census was 95 residents. Record review of the facility Resident rights policy revised 12/2016 showed the resident had the right to be treated with kindness, respect, and dignity. 1. Record review of Resident #14's admission Record showed he/she was admitted to the facility on [DATE] and had the following diagnoses: -Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). -Cerebrovascular Accident (CVA, stroke), cerebral artery occlusion with infarct (a blockage in the one or more of the arteries supplying blood to the brain resulting in a stroke). Record review of the resident's Care Plan dated 5/17/22 showed the resident: -Was independent with eating. -Needed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the residents received services in the facility with reasonable accommodation of residents needs and preferences to create a home-like environment by serving meals on Styrofoam plates or container and serving beverages in Styrofoam cups for six sampled residents (Resident #3, #340, #14, #44, #84 and #72) out of 19 sampled residents. The facility census was 95 residents. Record review of facility policy entitled Homelike Environment revised February 2021 showed: -Residents were provided with a safe, clean, comfortable and homelike environment. -Staff provided person-centered care that emphasized the residents' comfort, independence and personal needs and preferences. -The facility staff and management maximized, to the extent possible, the characteristics of the facility that reflected a personalized, homelike setting. -The facility staff and management minimized, to the extent possible, the characteristics of the facility 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 promote the right to self-determination and choices by not providing access to food when hungry and/or reasonable access to beverages for seven sampled residents (Residents #12, #21, #87, #14, #44, #3, and #4); and to assist with getting out of bed, getting dressed, and taken to the dining room when requested for one sampled resident (Resident #14) out of 19 sampled residents. This potentially effected all facility residents who were able to consume beverages and food provided by the facility kitchen. The facility census was 95 residents. Record review of the facility Resident Rights policy revised December 2016 showed the following rights: -A dignified existence. -Be treated with respect, kindness and dignity. -Self-determination. Record review of the facility Dignity policy revised February 2021 showed: -Each resident shall be cared for in a manner that promotes and enhances his/her sense of well-being, level of satisfaction with life,…

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 the Employee Disqualification List (EDL), Criminal Background Checks (CBC) and Nurse Aide (NA) Registry checks were completed to ensure potential employees did not have a Federal Indicator (FI - a marker given to a potential employee who has committed abuse, neglect, or misappropriation of property against residents) in accordance with the state and federal regulation prior to hire on four out of ten employees sampled. The facility census was 95 residents. Record Review of the Missouri Revised Statute Chapter 660, Section 660.317 showed, prior to allowing any person who has been hired as a full time part time or temporary position to have contact with any patient or resident, the provider shall, or in the case of temporary employees hired through or contracted for an employment agency, the employment agency shall prior to sending a temporary employee to a provider: -Request a criminal background check as provided in section 43.540, RSMo. Completion of an inquiry to the highway patrol for criminal records that 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 interview and record review, the facility failed to ensure that Comprehensive Care Plan meetings were held on admission and quarterly and to the extent practicable, the participation of the resident and the resident's representative(s), and an explanation was not included in the residents medical record why the participation of the resident and residents representative was determined to impractical for the development of the resident's care plan for three sampled residents (Resident #3, #68, and #84) out of 19 sampled residents. This potentially effected all facility residents who could participate in care plan meetings. The facility census was 95 residents. Record review of facility policy titled Care Planning-Interdisciplinary Team revised September 2013 showed: -The facility's care planning/interdisciplinary team was responsible for the development of an individualized comprehensive care plan for each resident. -A comprehensive care plan was developed within seven days of completion of the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Acetaminophen (an over the counter pain medication) orders were clarified to include parameters (a numerical or other measurable factor) for maximum dose per day for four sampled residents (Resident #68, #37, #72 and #84); and to ensure the pain medication order was confirmed and continued upon admission to the facility for one sampled resident (Resident #3) out of 19 sampled residents. The facility census was 95 residents. Record review of the facility Acute Condition Changes - Clinical Protocol policy, revised March 2018 showed: -The physician and nursing staff would review the details of any recent hospitalization. -The physician would help identify medications and medication combinations that were associated with adverse consequences that could cause significant changes in condition. Record review of the facility Administering Medication's policy, revised April 2019 showed: -If a medication dosage was believed to be excessive for a resident,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the staffing levels were adequate to meet the needs of the residents based on their acuity; and to ensure staffing levels were adequate to get residents dressed, out of bed, and to meals for two sampled resident (Resident #14 and #81) out of 19 sampled residents. This deficient practice potentially affected all residents who needed assistance with Activities of Daily Living(ADL's-dressing, transfers eating, mobility). The facility census was 95 residents. Record review of the facility's staffing policy dated 10/2017 showed: -The facility provided sufficient numbers of staff with the skills and competency necessary to provide care an services for all residents in accordance with resident care plans and facility assessment. -Staffing numbers and the skill requirements of direct care staff were determined by the needs of the residents based on the plan of care. Record review of the facility's Facility Assessment Tool, updated 4/15/22…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were not subjected to unnecessary psychotropic medications (drugs which affect psychic function, behavior, or experience); to ensure pro re nata (PRN, as needed or indicated) antipsychotic medications (a group of drugs affecting mental functioning such as mood, behavior, or thinking processes, commonly used to treat psychosis) were not prescribed for more than 14 days; to ensure an oral medication was ordered to try a lower dose of medication for behaviors; and to ensure non-pharmacologic interventions were implemented prior to administering PRN Intramuscular (IM) antipsychotic medication for two sampled residents (Resident #25 and #14); and to ensure documentation showed monitoring of behaviors and response to medications for one sampled resident (Resident #68) out of 19 sampled residents. The facility census was 95 residents. Record review of the facility's Antipsychotic Medication Use policy, revised December, 2016 showed:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents had sufficient alternate food choices at breakfast including one sampled resident (Resident #3) out of 19 sampled residents. This deficient practice potentially affected all residents who ate food from the kitchen. The facility census was 95 residents. Record review of the facility's Frequency of Meals policy revised 7/2017 showed alternate meals would be offered to residents who choose to eat non-traditional or outside of scheduled meal times. 1. Record review of the facility's undated Spring/Summer Menu Cycle showed: -The breakfast meal was outlined daily with food and beverages. -There was no alternate meal listed for breakfast. Record review of the facility's untitled, undated, alternate menu showed: -The alternate meal choices were lunch and dinner items. -There were no breakfast items listed for daily alternatives. During an interview on 9/19/22 at 10:35 A.M. Dietary Aide (DA) A said he/she was not aware of any…

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 the resident's wishes for advanced directives related to a Do not Resuscitate (DNR a directive indicating that, in case of respiratory or cardiac failure, the resident or legal representative had directed that no cardiopulmonary resuscitation (CPR - a lifesaving technique involving hard, fast chest compressions and/or rescue breaths/oxygen supplementation used when someone's breathing or heartbeat has stopped) code statuses were communicated to direct care staff and the physician and were reflected on the Physician Order Sheet (POS) and Care Plan for one sampled resident (Resident #42) out of 19 sampled residents. The facility census was 95 residents. Record review of the facility's Advanced Directives policy, revised 12-16-22 showed: -Upon admission the resident will be provided with written information concerning the right to formulate an advanced directive (a written instruction, such as a living will (a document specifying a person'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 to failed to notify the resident's physician when there was a missed medication and when blood sugars continued to be elevated for one sampled resident (Resident #3) out of 19 sampled residents. The facility census was 95 residents. Record review of facility policy titled Change in a Resident's Condition or Status revised February 2021 showed: -The facility would promptly notify the resident, his/her attending physician, and the resident representative of a change in the resident's medical/mental condition and/or status. -The nurse would notify the resident's attending physician when that had been: -A need to alter resident's medical treatment significantly. -Significant change in the resident's physical condition. -A significant change of condition is major decline in the resident's status that: -Would not normally resolve itself without intervention by staff of by implementing standard disease related clinical interventions. -Impacted more than one area 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 all alleged violations of resident abuse were reported to the State immediately or no later than two hours after the allegation was made for an incident of abuse involving two out of 25 sampled residents. Resident #25 was witnessed punching Resident #81, resulting in a bloody nose requiring an emergency room (ER) visit. The facility census was 99 residents. Record review of the facility's Abuse Investigation and Reporting policy, revised 7/2017, showed staff are required to immediately report any incident, allegation, or suspicion of potential abuse, neglect, exploitation, and misappropriation of resident property, mistreatment or a crime against a resident. 1. Record review of Resident #81's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning), date 8/22/22, showed the resident: - admitted to the facility on [DATE]; -diagnoses including Dementia (a chronic or persistent disorder 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 thoroughly investigate allegations of resident abuse by not conducting interviews and/or obtaining statements from all witnesses and by not reviewing pertinent information from nursing notes and incident reports and using the information to determine if abuse occurred. This deficient practice affected two residents (Resident #81 and #11) out of 25 sampled residents. The facility census was 99 residents. Record review of the facility's Abuse Investigation and Reporting policy, revised 7/2017, showed: -The Administrator will ensure any further potential abuse is prevented. -The individual conducting the investigation will, at minimum: --Review completed documentation. --Review the resident's medical record to determine events leading to incidents. --Interview persons reporting the incident, any witnesses, the residents and their roommates as appropriate, alleged perpetrator, attending physician to determine the resident's cognitive function…

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 the resident and the resident's representative in writing of a discharge including the reason for the transfer for one sampled resident (Resident #90) out of three sampled closed records. The facility census was 95 residents. 1. Record review of Resident #90's admission Record showed the resident: -Was admitted to the facility on [DATE] with a diagnosis of lung cancer. -Was at the facility for a rehabilitation stay. Record review of the resident's Discharge Instructions for Care form dated 8/1/22 showed the resident was being discharged to home. Record review of the resident's Progress Notes on 9/19/22 showed no information regarding a discharge transfer notice being given to the resident. During an interview on 9/20/22 at 9:24 A.M. Registered Nurse (RN) B said: -He/she completed the nursing part of the discharge including discharge medications. -He/she was not aware of a transfer/discharge letter that needed to be given to the resident upon…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, the facility failed to ensure the follow through of the Pre-admission Screening and Resident Review (PASARR) recommendations and integrate the recommendations into the care plan for one sampled resident (Resident #90) out of 19 sampled residents. The facility census was 95 residents. Record review of the facility's Behavioral Assessment, Intervention and Monitoring policy revised 2019 showed the Level II PASARR report would be used when conducting the resident assessment and developing the care plan. 1. Record review of Resident #90's admission Record showed he/she was admitted to the facility on [DATE] and had the following diagnoses: -Anxiety Disorder (a psychiatric disorder causing feelings of persistent anxiety). -Major depressive disorder (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living). -Bipolar disorder (a mental disorder that causes unusual shifts in mood,…

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 the resident and/or his/her representative with a copy of the baseline care plan for one sampled resident (Resident #341) out of 19 sampled residents. The facility census was 95 residents. Record review of the facility policy Care Plans-Baseline revised December 2016 showed: -A baseline care plan to meet the resident's immediate needs would be developed for each resident within 48 hours of admission. -The interdisciplinary team would review the health practitioner's orders and implement a base line care plan that met the resident's immediate care needs. -The baseline care plan would be used until staff conducted the comprehensive assessment and developed an interdisciplinary person-centered care plan. -The resident and his/her representative would be provided a summary of the baseline care plan. 1. Record review of Residents #341's admission record showed he/she was admitted to the facility on [DATE]. Record review of the resident's medical…

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 recapitulation of stay was completed; to have a clear discharge plan after a rehabilitations stay, and to document the disposition of belongings upon discharge for one sampled resident (Resident #90) out of three sampled closed records. The facility census was 95 residents. Record review of the facility's policy Discharge Summary and Plan revised 12/2016 showed: -When the facility anticipated a resident discharge to a private residence, a discharge summary and post-discharge plan would be developed. -The discharge summary would include a recapitulation of the resident's stay at the facility and a final summary of the resident's status upon discharge. 1. Record review of Resident #90's admission Record showed the resident: -Was admitted to the facility on [DATE] with a diagnosis of lung cancer. -Was at the facility for a rehabilitation stay. Record review of the resident's Discharge Instructions for Care form dated 8/1/22 showed: -The resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide an ongoing resident-centered activities program that provided daily meaningful involvement in activities of choice and included opportunities for individual expression, creativity, enjoyment, success and a sense of belonging and enhanced the physical, cognitive, and emotional well-being for two sampled residents (Residents #81 and #25) who could benefit from daily 1:1 and/or small group activities out of 19 sampled residents. The facility census was 95 residents. Record review of the facility's Activity Evaluation policy, revised June, 2018 showed: -An activity evaluation is conducted as part of the resident's comprehensive assessment that reflects the choices and interests of the resident and is used to develop an individual activities care plan. The resident's lifelong interests, spirituality, life roles, goals, strength, needs and activity pursuit patterns and preferences are included in the evaluation. -The activities director…

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 physician orders were followed for pressure-reducing boots for one sampled resident (Resident #81) who had a Pressure Injury (PI - localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) out of 19 sampled residents. The facility census was 95 residents. Record review of the National Pressure Injury Advisory Panel (NPIAP) definition of a Deep Tissue Injury showed: -A Deep Tissue Injury (DTI) was defined as intact or non-intact skin with localized area of persistent non-blanchable (skin that does not turn white when pressed) deep red, maroon, or purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin coloration changes. This injury results from intense and/or prolonged pressure and shear forces (resistance, such as gravity, between the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who required dialysis (process of cleansing the blood by passing it through a special machine - necessary when the kidneys were not able to filter the blood) receives ongoing assessments of the dialysis site, accurate description of resident's the dialysis site, and ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for one sampled resident (Resident #341) out of 19 sampled residents. The facility census was 95 residents. Record review of facility policy Hemodialysis (process of cleansing the blood by passing it through a special machine - necessary when the kidneys are not able to filter the blood) Access Care policy revised September 2010 showed: -Central dialysis catheters (type of access used for Hemodialysis. Catheters are placed under the skin and into a large central vein, preferably the internal jugular veins. Catheters are meant to be used for a short period…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent (%). Out of 25 observed medication opportunities, two errors occurred during insulin (Insulin is a hormone that lowers the level of glucose (a type of sugar) in the blood) administration resulting in an error rate of 8%. The facility census was 95 residents. Record review of the facility Insulin Administration policy revised September 2014 showed: -Onset of action is the characteristic of how quickly a type of insulin reaches the bloodstream and begins to lower blood glucose (sugar). -Rapid-acting insulin has an onset of 10 to 15 minutes. Record review of the facility Administering Medications policy revised April 2019 showed: -Medication administration times are determined by resident need and benefit, not staff convenience. -Factors that are considered for administration times included enhancing the optimal therapeutic effect of the medication. -References including manufacturer'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 that residents were free of significant medication errors by ensuring Intravenous (IV) medications were administered as ordered for one sampled resident (Resident #3) out of 19 sampled residents. The facility census was 95 resident's Record review of policy titled Administering Medications revised April 2019 showed: -The Director of Nursing (DON) supervised and directed all personnel who administered medications and/or related functions. -Medications were administered in accordance with the prescriber's orders, and included any required time frames. -Medication errors were documented, reported, and reviewed by the Quality Assurance Performance Improvement (QAPI) team. Record review of facility policy titled Administered Medications by IV push revised March 2022 showed: -Reported to physician, supervisor, and on coming shift any results, problems, or complications that occurred during the medication administration. 1. Record 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.