Big Spring Care Center For Rehab And Healthcare

Based on observation, interview, and record review, the facility failed to ensure staff treated all residents with dignity and respect when they did not provide a dignity bag for one resident's (Resident #34) Foley catheter (sterile tube inserted into the bladder to drain urine) bag (bag that collects urine drained from a catheter inserted into the bladder) and when staff yelled in the dining room, and when the facility smoking scheduled was at the same time as lunch causing smoking residents to choose between smoke break and a hot meal. The facility census was 44. Review of facility policy titled Procedure for Ensuring Resident Rights, dated 2025, showed the following: -Residents are encouraged to participate in the Resident Council; -The facility will support and facilitate resident-led discussions on improving care; -No staff member may interfere with or retaliate against residents for voicing concerns. 1. Review showed facility did not provide a policy related to catheter. Review of Resident #34's face sheet (brief information sheet about the resident) showed the following:…

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 act as a fiduciary and properly manage residents' funds when the facility failed to maintain access to a petty cash fund that ensured all resident could receive cash requests of less than $100.00 (or less then $50.00 if the resident received Medicaid) the same day for three residents (Resident #1, #26, and #44) out of a total sample of 17 residents. The facility census was 44. Review of the facility policy titled, Personal Needs Allowance (PNA), revised February 2019, showed the following: -All patients that the facility receives the original income checks in full are to be credited with $50.00 to their PNA account; -Petty cash in the amount of $750.00 is to be kept for small requests and should be replenished on a as needed basis; -All patients must sign their request and receipts acknowledging receipt of funds. (The policy did not address how quickly residents should be able to obtain their funds.) 1. Review of the resident council…

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 had a safe, clean, comfortable and homelike environment when a handrail in a common area remained in an unsafe condition, chair cushions in a common area were in disrepair, and two walls of one resident's (Resident #16) room were damaged. A sample of 17 residents was reviewed; the facility census was 44. Review of a facility policy entitled Maintenance Service, revised December 2009, showed the following: -The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times; -Functions of maintenance personnel include maintaining the building in good repair and free from hazards; -The Maintenance Director is responsible for maintaining work order requests. Review of the facility policy entitled Quality of Life - Homelike Environment, revised May 2017, showed the following: -Residents are provided with a safe, clean, comfortable and homelike environment; -Staff shall provide person-centered care that emphasizes the residents' comfort,…

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 have a system or records that showed provided an accurate reconciliation of controlled medications when facility's licensed staff failed to ensure the Emergency Kit (E-Kit) and the form titled BNDD (Bureau of Narcotics and Dangerous Drugs) Kit Administration Record matched the current narcotic count, when a random count of the narcotics in the E-Kit with the nurse did not match. The facility census was 44. Review of the facility provided policy titled BNDD Kit Policy, dated March 2019, showed the following: -The BNDD kit is owned, managed, and controlled by the long-term care facility; -The BNDD kit will be used when extenuating circumstances exist; -When accessing/opening the BNDD kit the nurse will contact the physician to obtain an order to access the BNDD kit and an order to administer the medication; -The nurse opening the BNDD kit will fill out the form titled Missouri Emergency Kit Order/Audit Form with a witness nurse; -A physical count will be performed on each medication each time the BNDD kit is…

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 assess the use of a seat belt, failed to obtain written consent for use of the seat belt, failed to document what less restrictive options were attempted, failed to document risk versus benefit review related to the seat belt use, failed to obtain a physician's order for use of the seat belt, and failed to care plan the use of the seat belt for one resident (Resident #11) who was unable to effectively and consistently remove the seat belt without staff assistance. The facility census was 44. Review of the facility provided policy titled Use of Restraints, dated December 2007, showed the following: -Restraints should only be used for the safety and well-being of the resident and only after alternatives have been tried unsuccessfully; -Restraints shall only be used to treat the resident's medical symptoms and never for discipline or staff convenience, or for the prevention of falls; -Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent…

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 staff failed to fully implement their abuse and neglect policies and procedures when staff failed to report an allegation of abuse made by one resident (Resident #1), who reported to the charge nurse that another resident (Resident #2) kissed him/her on the mouth, immediately to facility Administrator and within two hours to the state survey agency (Department of Health and Senior Services - DHSS). A sample of four residents was selected for review. The facility census was 46. Review of the facility's policy titled Abuse and Neglect Policy, revised September 2024, showed the following: -It was the policy of the home to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare had been or may be adversely affected by abuse or neglect caused by another person; -If there was any allegation of abuse, then 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 interview and record review, the facility failed to ensure all residents received care per professional standards of practice when staff failed to obtain ordered blood tests in a timely fashion for one resident (Resident #8) out of a total sample of 17 residents. The facility census was 44. Review of the facility's policy titled, Laboratory Services For Nursing Staff, dated 2025, showed the following: -The facility shall provide or arrange for laboratory services to meet residents' medical needs; -The nursing staff is responsible for coordinating, collecting, and documenting laboratory specimens in accordance with state and federal regulations; -All laboratory results must be reviewed, documented, and communicated to the provider in a timely manner. 1. Review of Resident #8's face sheet (gives basic profile information) showed the following information: -admission date of 08/31/22; -Diagnoses included atrial fibrillation (abnormal heartbeat), hyperlipidemia (high cholesterol), chronic kidney disease, and edema (swelling). Review of the resident's care plan, updated…

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 care for residents on oxygen per professional standards of practice when staff failed to administer oxygen per physician orders for two residents (Resident #5 and Resident #7). The facility census was 44. Review of the facility's policy titled Monitoring Oxygen Use and Oxygen Saturation, undated, showed the following: -Purpose to ensure the safe and effective use of oxygen therapy and comply with regulatory requirements; -Applies to all residents receiving oxygen therapy and the nursing staff responsible for their care; -Oxygen therapy must be prescribed by a physician, including flow rate (liters per minute - lpm) and oxygen saturation range; -Only licensed nurses may adjust oxygen flow rates based on the physician's order; -Record oxygen flow rate, delivery method, and saturation levels in the resident's medical record; -Document any changes, incidents, or interventions related to oxygen therapy; -Review incidents related 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 provide dialysis (the cleaning of the blood with a machine due to the kidneys not working) services per professional standards of practice when the facility failed to document routine assessment and monitoring of the dialysis site and failed to document ongoing communication with the dialysis center for one resident (Resident #2) who received dialysis. The facility census was 44. Review of the facility's policy titled Dialysis Policy, dated 2025, showed the following: -Purpose to establish guidelines for nursing staff to manage and support residents undergoing dialysis, ensuring safety, infection control, and continuity of care; -Confirm dialysis treatment orders, including type of dialysis (in-center, home, bedside), frequency and duration of treatments and access site type (arteriovenous-an abnormal connection between an artery and a vein (AV)) fistula, graft, catheter); -Obtain contact information for the dialysis center or provider; -Document baseline vital signs, lab results, and current medications;…

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 acknowledge, assess, provide supportive services, and to develop a care plan that showed interventions the facility staff would take to try to protect the resident and prevent trauma from recurring for one resident (Resident #1), out of 17 sampled residents, who informed staff of past trauma. The facility census was 44 residents. Review of the facility's policy entitled Trauma-Informed Care, dated 2025, showed the following: -The facility will provide trauma-informed care (TIC) that recognizes, assesses, and responds to the effects of trauma on residents; -Staff will be trained in trauma-informed care principles, focusing on psychological safety, trust, and individualized care; -The facility will integrate evidence-based interventions and coordinate with behavioral health providers when necessary; -Person-centered approaches will be used to reduce re-traumatization and support residents in their recovery; -Upon admission screen all residents for history of trauma (physical, emotional, medical, or war-related…

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 a functional environment for all residents, when staff failed to maintain a bariatric Hoyer weight scale when staff were unable to take a weight on one resident (Resident #8), out of a total sample of 17 residents, for six months for one resident. The facility census was 44. Review of the facility's policy titled Weight Assessment and Intervention, revised September 2008, showed the following: -The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents; -The dietician will review the unit weight record monthly to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight changes has been met. 1. Review of Resident #8's face sheet (gives basic profile information) showed the following information: -admission date of 08/31/22; -Diagnoses included atrial fibrillation (abnormal heartbeat), hyperlipidemia (high cholesterol), chronic kidney disease, 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 administer their resources in a an effective manner to assure the highest practical well-being of all residents when the facility failed pay their DME (durable medical equipment) company per their rental agreement by the due date to ensure residents' medical equipment could remain in the building. This resulted in the company arriving on site to take back equipment actively being used by residents. This had the potential to affect all residents in the facility. The facility census was 45. 1. Review of the facility's DME invoices showed the following: -An invoice, dated 12/31/21, stamped past due, with a due date of 01/30/22. The invoice total was $2123.00 with a balance due after last payment of $325.50; -An invoice, dated 01/31/22, stamped past due, with a due date of 03/02/22. The invoice total was $3200.30 with a balance due after last payment of $527.00; -An invoice, dated 02/28/22, stamped past due, with a due date of 03/30/22. 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 ensure food was stored, prepared, and distributed in a manner to prevent possibly contamination when staff failed to maintain food contact services as clean, failed to keep ice machine free of black substances, failed to store bulk food scoops outside of the the containers, and failed to date and store refrigerated foods appropriately. This had the potential to affect all residents who consumed food from the facility kitchen. The facility census was 51 1. Review of the 2013 Missouri Food Code showed food-contact surfaces of equipment and utensils shall be clean to sight and touch. Review of the facility's Policy & Procedure Manual, Chapter 3: Food Production and Food Safety, General Food Preparation and Handling showed the following: -The kitchen will be kept neat and orderly; -The kitchen surfaces and equipment will be cleaned and sanitized as appropriate. Observations of the kitchen on 4/11/2023, beginning at 9:11 A.M., and on 4/12/2023 at 10:53 A.M., showed the following: -Two metal shelves used to store…

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 sanitary environment when staff failed to keep non-food contact surfaces, including the floor, vents, ceiling lights, and the outside of the dishwasher, clean and well maintained in the kitchen, dry storage area, and dining rooms. This has the potential to affect all residents who consumed food from the facility. The facility census was 51. Review of the Food and Drug Administration (FDA) 2013 Food Code showed non-food contact surfaces shall be kept free of an accumulation of dust, dirt, food residue, or other debris Review of the facility's Policy & Procedure Manual, Chapter 3: Food Production and Food Safety 3-26, General Food Preparation and Handling showed the the kitchen will be kept neat and orderly. The kitchen surfaces and equipment will be cleaned and sanitized as appropriate. Review of the facility's cleaning schedules showed staff did not document completion of the cleaning schedules. 1. Observations on 4/11/2023, beginning at 9:11 A.M., and on 4/12/23, beginning at 10:53 A.M., 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, observation, and record review, the facility failed to follow their emergency water supply procedures when staff did not have a three day supple of water on hand for use in the case of loss of normal water supply. The facility census was 51. Review of an agreement letter with a water provider, undated, showed the following information: -The provider will assist in supplying bottled water to the facility in the event of a fire, hurricane, tornado, flood or loss of power in or around the facility; -Adequate water will be provided to service the facility's residents: 1.5 gallons of water per day per resident, family members and staff; -Response should be available within 48 hours of notification; however, is subject to facility accessibility and availability of delivery equipment and products consistent with the nature of the emergency event; -The company recommends that the facility maintain a three day water supply on site at all times. Review of a facility appendix to the Emergency Operations Plan entitled Disaster Water Supplies, undated, showed the following:…

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 complete a Criminal Background Check (CBC) on two of ten sampled staff (Dietary Aide (DA) O and Maintenance Supervisor) and failed to ensure that three staff (Certified Nurse Aide (CNA) H, DA O, and Maintenance Supervisor) were not on the Missouri Employee Disqualification List (EDL - a list of individuals who are determined to be not able to work in long term care). A sample of 10 staff were reviewed in a home with a census of 51. Review of the facility provided policy, titled Background Checks Policy and Procedure, undated, showed the following information: -To comply with this responsibility, any and all owners, directors, officers, clinical staff, employees, vendors, independent contractors, volunteers, consultants and others working for the facility (Associates) that come in contact with residents are required to submit background checks; -New Associates must complete and return the attached criminal history record disclosure consent form to the facility Human Resources Director; -Associates shall be checked against…

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 give written transfer notice to the resident and/or resident's representative for six residents (Residents #3, #14, #13, #26, #32, and #35) who were transferred out to the hospital. A sample of of 18 residents were reviewed in a facility with a census of 51. Review showed the facility did not provide a policy pertaining to written transfer notices of a resident's transfer to the hospital. Review of the facility provided policy, titled Transfer or Discharge Documentation, dated December 2016, showed the following information: -When a resident is transferred or discharged , detail of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider; -When a resident is transferred or discharged from the facility, the following information will be documented in the medical record: -The basis for the transfer or discharge: -That an appropriate notice was provided to the resident and/or legal representative; -The date and time 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 all residents received a written notice of the bed-hold policy upon transfer when staff failed to provide six residents (Residents #3, #14, #13, #26, #32, and #35) of 18 sampled residents, written notices of the facility's bed-hold policy when transferred to the hospital. The facility census was 51. Review of the facility provided policy, titled Bed Holds and Returns, undated, showed prior to transfers and therapeutic leaves, residents' representatives will be informed in writing of the bed-hold and return policy; 1. Review of Resident 3's face sheet (gives basic profile information) showed an admission date of 12/16/22. Review of the resident's nurses' notes showed the following: -On 03/09/23, at 3:30 P.M., resident complained of shortness of breath and anxiety. Vital signs and oxygen saturation level stable and within normal limits. Resident educated to breathe in through the nose and out the mouth. Resident began saying, I'm scared, I can't breathe. Licensed practical nurse (LPN) attempted to reassure 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 obtain physician's order for and care plan the use of side rails for one resident (Resident #10) and failed to obtain written consent for side rail use, failed to complete a documented side rail assessment including risks versus benefits,and failed to complete gap assessments prior to installing side rails for three residents (Residents #10, #33, and #9) in a sample of 24 residents. The facility census was 51. Review of the facilities policy, titled Bed Safety, revised December 2007, showed the following: -Resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment; -To prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard and bed accessories), the facility shall…

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 use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants, when staff failed to use appropriate hand hygiene while completing incontinent care for one resident (Resident #150) for one of 18 sampled residents Staff failed to complete and fully document tuberculosis (TB - infectious bacterial disease characterized by the growth of nodules (tubercles) in the tissues, especially the lungs) testing for three staff members (Certified Nurse Aide (CNA) H, Maintenance Supervisor, and Certified Medication Tech (CMT) B), in a sample of 10 staff members. The facility failed to accurately place, read, and record admission tuberculosis (testing for one resident (Resident #150) in a timely manner, out of a sample of 18 residents. The facility census was 51. Review of facility policy titled Handwashing / Hand Hygiene, dated 10/11/22, showed the following information: -This facility considers hand hygiene the primary means to prevent the spread of infections; -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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to assure five residents (Residents #9, #32, #44 #102, and #150) were offered any pneumococcal vaccinations (protects against serious and potentially fatal pneumococcal infections - also known as the pneumonia vaccines. Pneumococcal infections can lead to pneumonia, blood poisoning (sepsis) and meningitis) out of a sample of 18 residents. The facility census was 51. Record review of the Centers for Disease Control and Prevention (CDC) Pneumococcal Vaccine Timing for Adults, dated 03/15/23, showed the following information: -Two pneumococcal vaccines are recommended for adults; -CDC recommends vaccinations with the pneumococcal conjugate vaccine (PCV13 or Prevnar 13) for all adults 65 years or older and people 19 through 64 years with certain medical conditions, including chronic (ongoing) conditions; -CDC recommends vaccination with the pneumococcal polysaccharide vaccine (PPSV23 or Pneumovax 23) for all adults 65 years or older regardless of previous…

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 complete a baseline care plan (the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) within 48 hours for one resident (Resident #150) out of a sample of 18 residents. The facility had a census of 51. Review of the facility provided policy, titled Care Plans - Baseline. undated, showed the following information: -A baseline care plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission; -To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission; -The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan; -The resident and their representative will be provided a summary of the baseline care plan that includes but is not limited to the initial goals of the resident; 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, record review, and interview, the facility failed to ensure a resident's choice of code status (amount of medical assistance the resident wishes to receive if found though pulse or respirations) matched throughout the medical record for one resident (Resident #26) out of 18 sampled residents. The facility census was 51. Review of the facility policy, titled Do Not Resuscitate Order, dated [DATE], showed the following information: -The facility will not use cardiopulmonary resuscitation (CPR - giving strong, rapid pushes to the chest to keep blood moving through the body) and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order (DNR - instructs health care providers not to do CPR if a person's breathing stops or the heart stops beating) in effect; -DNR orders must be signed by the resident's attending physician on the physicians order sheet maintained in the resident's medical record; -A DNR order form must be completed and signed by…

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

Based on record review and interview, the facility failed to ensure a medication regimen was free from unnecessary medications when the facility failed to implement gradual dose reductions (GDR) for one resident (Resident #39) in a selected sample of 16 residents. The facility's census was 51. Review showed the home did not provide a policy addressing GDRs. 1. Review of Resident #39's face sheet (gives basic profile information) showed the following: -admission date of 01/11/22; -Diagnoses included Alzheimer's disease, unspecified intellectual disabilities, unspecified psychosis not due to a substance or now physiological condition, recurrent major depressive disorder with psychotic symptoms, vascular dementia with behavioral disturbance, anxiety disorder, and impulse disorder. Review of the resident's Physician Order Sheet (POS), current as of 04/14/23, showed an order, dated 03/31/22, for mirtazapine (antidepressant) 15 milligram (mg) tablet, give 15 mg by mouth at bedtime for depression. Review of the resident's care plan, last updated 03/01/23, showed the following information:…

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 clean surfaces in a clean sanitary manner and failed to store and air dry drinking glasses in a sanitary manner. The facility census was 42. Record review of the facility's policy, titled Sanitization, dated 2001 and revised October 2008, showed the following: -All kitchens, kitchen areas, and dining areas shall be kept clean, free from litter ad rubbish and protected from rodents, roaches, flies and other insects; -All utensils, counters, shelves and equipment shall be kept clean. 1. Observation of the kitchen on 12/09/19, at 9:20 A. M., showed the following: -The window ledge just above the sink had approximately 75-100 small flies, lying dead across the surface of the ledge; -One fly was squished on the window, about half way up; -The round, white eating utensils canisters (used to hold utensils when run through the dishwasher), sat on the window ledge; -Some small, wet, dead flies also observed smashed underneath the canisters. During an interview on 12/09/19, at 2:55 P. M., the dietary manager…

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, record review, and interview, the facility failed to obtain a physician's order for the placement and maintenance of a percutaneous endoscopic gastrostomy (PEG tube - feeding tube directly into the stomach), to include a valid, clinical rationale for the PEG tube, for one resident (Resident #35). A sample of 12 residents was selected for review; the facility census was 42. Record review of the facility's policies showed the facility did not provide a policy for what PEG tube orders should include or labeling requirements of the bag. 1. Record review of Resident #35's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/7/19, showed the following information: -Most recent readmission to the facility 10/23/19; -Diagnoses included high blood pressure, diabetes, stroke, difficulty with speech, one-sided weakness, anxiety, malnutrition or risk for, and COPD (chronic obstructive pulmonary disorder); -Total dependence on staff for all activities of daily living (ADLs) including eating/intake; -Received 51%…

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 informed consent for the use of side rails and failed to complete side rail safety checks and regular inspections of the bed frame and side rails for the risk of entrapment for two residents (Resident #16 and #24) . A sample of 12 residents was selected for review; the facility census was 42. Record review of the facility's policy entitled, Proper Use of Side Rails, dated 2001 and revised December 2016, showed the following information: -Side rails are considered a restraint when they are used to limit the resident's freedom of movement; -Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents; -An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails; -When used for mobility or transfer, an assessment will include a review of the resident's bed mobility, ability to change positions, 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.