Villages Of Jackson Creek

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accurately assess a resident's Percutaneous Endoscopic Gastrostomy tube (PEG tube - a tube that is placed into a patient's stomach as a means of feeding them when they were unable to eat) for proper placement while administering medications; failed to ensure liquid nutrition was received as prescribed daily; failed to label the tube feeding bags accurately according to accepted nursing standards of practice; failed to document and monitor the amount of nutrition and water that was provided daily to ensure physician's orders were followed; facility failed to ensure liquid nutrition was received as prescribed daily; failed to label the tube feeding bags accurately according to accepted nursing standards of practice; failed to document and monitor the amount of nutrition and water that was provided daily to ensure physician's orders were followed; and failed to check for residual fluids in the resident's stomach while administering…

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 monthly medication regimen reviews (MRR) were reviewed and recommendations were followed within a timely manner for two sampled residents (Resident #15 and #59) out of 22 sampled residents. The facility census was 108 residents.Review of the facility's policy titled Medication Regimen Reviews dated May 2019 showed:-The Consultant Pharmacist performed a MRR for every resident in the facility receiving medication.-MRRs were done upon admission and at least monthly thereafter, or more frequently if indicated.-The goal of the MRR was to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication.-The MRR involved a thorough review of the resident's medical record to prevent, identify, report and resolve medication problems, medication errors and other irregularities.1. Review of Resident #15's admission Record showed he/she was admitted to the facility with the following diagnoses:-Chronic Pain Syndrome (pain that lasts over three months).-Anxiety Disorder (any group of…

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

Based on observation, interview, and record review, the facility failed to provide a choice of food for three days for one sampled resident (Resident #9) out of 22 residents who received room trays. The facility census was 108 residents.Review of the facility's Food and Nutrition Services Policy revised dated 2017 showed:-Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. -The multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident's nutritional needs, food likes, dislikes and eating habits, as well as physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization. -A resident-centered diet and nutrition plan will be based on this assessment.-Reasonable efforts will be made to accommodate resident choices and preferences.-Food and nutrition services staff will inspect food trays to ensure the correct meal is provided to each…

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 notify one sampled resident's (Resident #1) physician of the resident's refusal of his/her dialysis medication and late administration of the resident's sliding scale insulin, out of seven sampled residents. The facility census was 99 residents. Review of the facility Change in a Resident Condition or Status policy dated 2001 showed: -The facility was to promptly notify the resident's attending physician of changes in the resident's medical/mental condition and/or status. -The licensed nurse would notify the resident's attending physician or physician on call when a resident refused treatment or medications at least two consecutive times. 1. Review of Resident #1's Physician's Orders Sheet (POS) dated April 2025 showed: -Diagnoses of end stage renal disease, dependence on renal dialysis, and diabetes. -Insulin Lispro (a fast-acting insulin that starts to work about 15 minutes after injection, has its most significant effect on lowering blood sugar levels in about 1 hour, and keeps working for 2 to 4 hours)…

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 sampled resident's (Resident #1) refusal of medications, omission of and late administration of medications was correctly documented and communicated to facility management; and failed to revise the resident's care plan to address the resident's refusal of medications, out of seven sampled residents, and failed to have a policy to address sliding scale insulin. The facility census was 99 residents. Review of the facility Insulin Administration policy dated 2001 showed: -Rapid-acting insulin has an onset of 10-15 minutes, a peak of 30 minutes to one hour and a duration of 3-6 hours. -The policy did not address sliding scale insulin. Review of the facility Administering Medications policy dated 2001 showed: -Medications are administered in accordance with prescriber orders, including any required time frame. -Medication administration times are determined by resident need including enhancing optimal therapeutic effect of the medication. -Medications are administered within one hour of their prescribed…

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 communication between the facility and dialysis (a procedure that uses a machine to filter blood when the kidneys were no longer able to do so) provider to provide coordinated and consistent care for one sampled resident (Resident #1) with end stage renal disease (permanent kidney failure that requires a regular course of dialysis) out of seven sampled residents. The facility census was 99 residents. Review of the facility End-Stage Renal Disease policy dated 2021 showed: -The resident's comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care. -There would be communication between the dialysis clinic and the facility. 1. Review of Resident #1's Physician's Orders Sheet (POS) dated April 2025 showed: -Diagnoses of end stage renal disease, dependence on renal dialysis. -Dialysis Monday, Tuesday, Wednesday and Friday. During an interview on 4/9/25 at 2:20 P.M. the resident's dialysis clinic nurse said: -For about two months there had been no written communication between 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 ensure infection control measures when applying a dressing over one sampled resident's (Resident #1's) central venous catheter (CVC - a tube inserted into a large vein, often in chest, or groin, and used for various purposes, including hemodialysis - dialysis a procedure that uses a machine to filter blood when the kidneys were no longer able to do so), out of seven sampled residents. The facility census was 99 residents. Review of the facility Central Venous Catheter Care and Dressing Changes policy dated 2001 showed: -The purpose of the procedure was to prevent associated complications including catheter-related infections associated with contaminated (exposed to germs, bacteria, or other foreign particles), loosened, soiled (dirty, regardless of the source of the dirt), or wet dressings. -Perform site care and dressing change immediately if the integrity of the dressing is compromised- damp loosened or visibly soiled. -Open sterile dressing kit. -Apply mask. -Apply sterile gloves. -Clean catheter insertion…

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 nursing staff notified the next of kin, physician, and department heads when one sampled resident (Resident #1) missed dialysis on 10/22/24 and 10/24/24, had increased blood pressure, and had a fall on 10/25/24. The resident was hospitalized on [DATE]. The facility census was 91 residents. Review of the facility Coordination of Care Policy, dated 5/20/24, showed: -The purpose of the policy was to establish a framework for effective coordination of care for the residents in the facility. -The policy aims to enhance communication among interdisciplinary team members, ensure continuity of care, and improve health outcomes for residents. -Care coordination will be facilitated through effective communication, shared decision-making, and the involvement of residents and their families in the care planning process. -Regular interdisciplinary (IDT) team meetings will be held at least weekly to discuss resident care plans, progress, and any necessary…

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 remove grime from the top of the garbage disposal (a device, installed under a kitchen sink between the sink's drain and the trap used to shred food waste into pieces small enough--less than 2 mm -- in diameter, to pass through plumbing); to remove a buildup of grime and debris including drinking cups from under the ice machine; to remove debris from around the nozzles of the juice machine; to ensure that Dietary Aide's (DA) A's hair was fully covered; to place a label to identify an unknown substance that was in a bottle on the shelf above the stove; to label a white powdery substance in a container in a dry goods' storage to identify that item; and to maintain the milk at 400 Hall kitchenette at a temperature of 41 ºF (degrees Fahrenheit) or colder. This practice potentially affected all residents. The facility census was 105 residents. 1. Observation on 4/29/24 from 9:11 A.M. through 9:36 A.M., during the initial kitchen observations, showed: -A buildup of grime under the dishwasher. -A small leak from the garbage…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain the commode risers (assistive devices to improve the accessibility of toilets to older people or those with disabilities. They can aid in transfer from wheelchairs and may help prevent falls) in resident rooms [ROOM NUMBERS] in an easily cleanable condition. The facility also failed to maintain three mechanical lifts on the 300 Hall and three mechanical lifts on the 400 Hall in sound condition. This practice potentially affected 12 residents, who resided on the 300 and the 400 Halls, who depended on mechanical lifts for transfers and two residents who used commode risers. The facility census was 105 residents. 1. Observation with the Maintenance Director on 4/30/24, showed: -At 10:17 A.M., there was an area on the commode riser in resident room [ROOM NUMBER] that was not easily cleanable. -At 11:52 A.M., there was a crack in the commode riser in resident room [ROOM NUMBER]. During an interview on 5/10/24 at 12:59 P.M., 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 observe the resident while he/she took his/her medications, left the medications on the resident's bedside table for one sampled resident (Resident #88), and to assess the resident for safety of self-administering medications for three sampled residents (Resident #88, #6, #71) out of 21 sampled residents. The facility census was 105 residents. Review of the facility's policy titled Self-Administration of Medications dated 1/1/19 showed: -An assessment should be conducted by a member of the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out the responsibility of self-administration of medications. -A skills assessment should be conducted quarterly or if needed when there was a change in condition. Review of the facility's policy titled Bedside Medication Storage dated 1/1/19 showed there should be a written order for the bedside storage of medication. 1. Review of Resident #88's admission record…

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 make pureed (cooked food, that has been ground, pressed, blended or sieved to the consistency of a creamy paste or liquid) eggs in a palatable manner and to maintain hot foods on room trays during the breakfast meal, at or close to 120 ºF (degrees Fahrenheit) when those trays were delivered to the residents. This practice potentially affected at least six residents who resided on the 300 Hall. The facility census was 105 residents. 1. Review of the undated recipe for pureed eggs showed: -Boil eggs for three minutes and allow to sit in the water covered for 20 minutes. -Remove eggs from water and immerse in cold water to cool. -Crack shells and rinse well with water to remove all shells. -For puree diets, prepare items per regular recipe. Portion number of servings needed based on diet census and puree. Refer to therapeutic menu for appropriate portion size of puree foods. -There were no seasonings such as salt or any spices that were…

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

Based on observation, interview and record review, the facility failed to ensure that food in the resident use refrigerator was labeled and resident's name and the date the food item was brought in in accordance with the facility's policy. This practice potentially affected an unknown number of residents who have foods brought in by visitors. The facility census was 105 residents. Review of the facility's policy entitled Safe Food Handling for Food Brought in From Outside Sources, dated 11/17, showed: -Food and/or beverages brought into the healthcare center from the outside will be monitored by center partners for contamination, spoilage, and overall food safety. -Food and/or beverage items brought into the center should be securely packaged and labeled with the patient's name and the date the item(s) were brought into the center. The center should have large zip type storage bags and markers, or other appropriate supplies, available for packaging, labeling and identifying food brought in from an outside source. -Food or beverage items will be monitored and discarded by the center…

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 hand hygiene, use of a barrier for supplies and cleansing of the glucometer during blood glucose monitoring (a blood sugar reading obtained from a small sample of blood from the finger) and administration of insulin (mediation that helps blood sugar enter the body's cells for use as energy) for three sampled residents (Resident #68, #91, and #39) out of 21 sampled residents and to ensure a policy to ensure staff correctly sanitized the glucometer between use for residents. The facility census was 105 residents. Review of the facility Hand Hygiene policy, updated August 2021 showed: -Hand hygiene included both handwashing with soap and water and use of alcohol-based products (gels, rinses, foams) that do not require the use of water. -In the absence of visible soiling of hands, approved alcohol-based products for hand disinfection are preferred over antimicrobial or plain soap and water because of their superior microbiocidal…

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 resident with a major mental illness diagnosis had a required DA-124C/Level I Preadmission Screening and Resident Review (PASARR - used to evaluate the presence of psychiatric conditions to determine if a PASARR Level II screen is required) in a timely manner for care planning purposes for one sampled resident (Resident #65) out of 21 sampled residents. The facility census was 105 residents. Review of the facility's PASARR policy, revised 11/2016 showed: -The DA-124C (PASARR Level I) must be completed on all potential residents prior to admission to screen individuals for mental illness (MI) and intellectual/developmental disability (ID/DD) or related conditions regardless of the resident's method of payment or known diagnoses. It must be determined if the individual requires the level of services provided by the facility or if they need specialized treatment for MI or ID/DD diagnosis. -For residents appropriate for a PASARR Level II 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide an ongoing activity program based on a comprehensive assessment and care plan of each resident's interests, hobbies, and abilities for two sampled residents (Residents #7 and #44) out of 21 sampled residents. The facility census was 105 residents. When a policy for Activities was requested, the facility provided a training manual titled Missouri Health Care Association Activity Director Training Binder dated 3/8/17. There was no facility policy specific to activities included in the manual. The manual did include the State Operations Manual (SOM) Activity Regulation and guidance for this regulation. 1. Review of Resident #7's undated admission record that was printed on 5/2/24 showed: -The resident was receiving hospice care (end of life care). -Some of the resident's diagnoses included psychosis (a mental disorder characterized by a disconnection from reality), anxiety disorder (psychiatric disorder that involve extreme fear,…

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 adequate fall prevention interventions were added to a care plan in a timely manner and implemented for one sampled resident (Resident #6)with a history of falls. The facility failed to ensure staff utilized a gait belt (a safety device placed around the waist of residents requiring assistance with transfers and walking) for one sampled resident (Resident #226) who required assistance with transfers out of 21 total sampled residents. The facility census was 105 residents. Review of the facility's Investigating and Reporting Accidents and Incidents policy, revised July, 2017 showed: -The Nurse Supervisor/Charge Nurse and/or department director or supervisor shall promptly initiate and document investigation of an accident/incident and shall complete a Report of Incident/Accident form. -The Director of Nursing (DON) shall ensure the Administrator receives a copy of the Report of Incident/Accident form. -Incident/Accident reports will…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 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) received ongoing assessments of the dialysis site and accurate description of resident's the dialysis site for one sampled resident (Resident #374) out of 21 sampled residents. The facility census was 105 residents. Review of facility policy End-Stage Renal Disease (ESRD - inability of the kidneys to excrete wastes, concentrate urine, and conserve electrolytes), policy revised September 2010 showed: -Residents with ESRD, would be cared for according to currently recognized standards of care. -Type of assessments data that was to be gathered about the resident's condition on a daily or per shift basis. A policy was requested for dialysis care was requested but the facility had no policy. 1. Review of Resident #374's admission Record showed he/she was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a comprehensive Post Traumatic Stress Disorder (PTSD - a mental health condition triggered by a terrifying event. Symptoms may include flashbacks, nightmares, and severe anxiety) care plan was in place and that staff were educated on ways to decrease the resident's exposure to triggers and decrease the effects of a trigger for one sampled resident (Resident # 65) out of 21 sampled residents. The facility census was 105 residents. The facility's Trauma Informed Care process, undated, showed: -The Abbreviated PTSD Checklist for Civilians (PCL -C), a two-item version, would be used within 72 hours of admission. -If there were positive screen results a six-item version of the PCL-C would be completed for the resident's five-day assessment. -Residents who have a trauma history will have access to trauma-sensitive and behavioral health treatment as appropriate. -Staff members will need skills and guidance on identifying symptoms of trauma and acting…

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 facility considered all appropriate alternatives prior to installing bed rails for one sampled resident (Resident #6) with a history of falling from bed out of 21 sampled residents. The facility census was 105 residents. Review of the facility's Bed Entrapment Prevention policy, dated 11/18/21 showed: -The facility was restraint-free. -Full, half or quarter rails were only used by rare exception and only after proper assessment. -Bed canes (a device attached to the bed) were considered assistive devices. Review of the facility's in-service training for bed entrapment and bed rail utilization, dated 8/4/22 showed: -Bed rails were considered restraints and the facility didn't use them. -Bed assist bars were enablers that allowed the resident more mobility and needed to be properly identified on the Bed Rail Observation/Assessment form since they could still potentially be an entrapment risk, depending on the resident and their…

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 one sampled resident (Resident #6) with bed rails had rails that were compatible with the bed and were installed and maintained in a safe manner out of 21 sampled residents. The facility census was 105 residents. Review of the facility's Bed Entrapment Prevention Policy, dated 11/18/21 showed: -The facility's goals were: --Improved bed safety. --Mitigating the risk of entrapment. --Testing bed rails across all seven potential zones of entrapment. -Full, half, or quarter rails were only used by rare exception. Review of the facility's Bed Entrapment/Bed Rail Utilization training report, dated 8/4/22, showed: -A hospital bed manufacturer's Bed Entrapment diagram and information, dated 2009, was part of the training. The manufacturer's information referenced the Food and Drug Administration (FDA) Hospital Bed Safety webpage. -Signatures for the training included several nursing staff and the facility's current Maintenance Supervisor.…

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 keep the kitchen, Dry Storage room, and walk-in refrigerator and walk-in freezer floors clean and free from pests; to safeguard against foreign material possibly getting into food and/or beverages; to keep trash and garbage receptacles lidded; to properly document food temperatures to ensure they were suitably cooked to lessen the chance of bacterial contamination; to maintain plastic cutting boards and utensils in good condition to avoid food safety hazards; and to separate damaged foodstuff. These deficient practices potentially affected all residents, visitors, volunteers, or staff who ate food from the kitchen. The facility's census was 98 residents with a licensed capacity for 120 residents. 1. Observations during the initial kitchen inspection on 8/3/22 between 9:03 A.M. and 11:18 A.M. showed: -In the food tray pick-up room the ice machine had two large rusted areas approximately 3 square inches on both bottom corners of the plastic…

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 monthly pharmacy medication regimen reviews (MRR) for two sampled residents (Resident #30 and #73) and to provide physician/prescriber responses to MRR for six out of 12 months for two sampled residents (Resident's #13 and #82) out of 20 sampled residents. The census was 98 residents. Record review of the facility's Consultant Pharmacist Reports Policy, dated 1/1/19, showed: -The consultant pharmacist performs a comprehensive review of each resident's medication regimen and clinical record at least monthly. -The MRR includes evaluation of the resident's response to medication therapy to determine that the resident maintains the highest practical level of functioning and preventing or minimizing adverse consequences related to medication therapy. -The MRR also involves a thorough review of the resident's record and may include collaboration with other members of the interdisciplinary team, the resident, and the family members or other 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 each resident's drug regimen had diagnoses or adequate indications for each medication for five sampled residents (Residents #140, #64, #13, #30 and #73) and one supplemental resident (Resident #190) out of five sampled residents and one supplemental resident sampled for unnecessary medications out of 20 sampled residents. The facility census was 98 residents. Record review of the facility's medication and treatment orders policy dated as revised July 2016 showed orders for medications must include the clinical condition or symptoms for which the medication is prescribed. 1. Record review of Resident #140's current face sheet showed he/she was admitted to the facility on [DATE] related to kidney disease and his/her diagnoses included diabetes (a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin), anxiety disorder (psychiatric disorders that involve extreme fear, worry and nervousness) and depression (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 maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases when the facility failed to provide Tuberculosis (TB-a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) testing for one sampled resident (Resident #64) and one supplemental resident (Resident #191) out of 20 sampled residents and 11 supplemental residents. The census was 98 residents. Record review of the facility's Early Identification and Management of Persons Suspected of Having Tuberculosis Disease Policy, dated February 2022, showed: -Screening and Surveillance of Residents: --A physician's order for a Two-Step Tuberculin Skin Test (TST) should be requested upon admission. --Each resident will receive a two-step TST upon admission unless they have a history of a positive TST or have a documented negative TST within the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide eye drops as ordered for one sampled resident (Resident #74) out of 20 sampled residents. The facility census was 98 residents. Record review of the facility's medication and treatment orders policy dated as revised July 2016 showed medications shall be administered following written orders. 1. Record review of Resident #74's current face sheet showed: -The resident was admitted to the facility on [DATE]. -The resident's primary diagnosis was an irregular heartbeat. -No diagnoses were listed that were related to glaucoma (a condition of increased pressure inside the eye which could lead to blindness) or any other eye disorders. Record review of the resident's current care plan with multiple dates showed no reference to the resident's eye drops or the resident's vision. Record review of the resident's Medication Administration Record (MAR) dated July 2022 showed: -A physician's order dated 7/8/22 for one drop of Timolol Maleate 0.5 % (used to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their fall policy which include completing and thoroughly documenting an unwitnessed fall; a fall investigation; and documenting for 72 hours after a fall for one sampled resident (Resident #30) out of 20 sampled residents. The facility census was 98 residents. Record review of the facility's Falls policy dated March 2018 showed: -The staff and physician will document in the medical record a history of one or more recent falls. -The nurse shall assess and document/report the following: --Vital signs (VS-determination of temperature, pulse rate, rate of breathing, level of blood pressure, and oxygen saturation). --Recent injury, especially fracture or head injury. --Musculoskeletal function, observing for change in normal range of motion (ROM - the range on which a joint can move), weight bearing, etc. --Change in cognition or level of consciousness. --Neurological status (Neuro Checks-assessing mental status, level of alertness, motor 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 ensure an as needed anti-anxiety (used to treat symptoms of anxiety, such as feelings of fear, dread, uneasiness, and muscle tightness, that may occur as a reaction to stress) medication order had a limit of 14 days for one sampled resident (Resident #140) out of 20 sampled residents. The facility census was 98 residents. Record review of the facility's medication orders for stop orders policy dated 1/1/19 showed: -As needed psychoactive (pertaining to a drug or other agent that affects such normal mental functioning as mood, behavior, or thinking processes) medications were to be automatically stopped after 14 days. -When the prescriber gave an order for a medication covered by the stop order policy, the nurse could request a specific duration for that order. -When entering medications covered by the stop order policy on the Medication Administration Record (MAR), the automatic stop date was to be recorded in the appropriate area on the MAR. 1. Record…

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.