Jefferson City Manor Care Center

Based on interview and record review, facility staff failed to ensure continuing competence of nurse aides of no less than 12 hours in-service education per year and address areas of weakness as determined in nurse aides' performance reviews and the facility assessment. The facility census was 55. 1. Review of the facility's policies showed staff did not provide a policy for staff training. Review of the Facility Assessment, dated 02/13/25, showed the following new hire training for nursing staff: -Advanced directives; -Effective communication; -Preventing, recognizing and reporting abuse; -Workplace safety; -Hand hygiene; -Health Insurance Portability and Accountability (HIPPAA), a law that protects the privacy of medical information, overview; -Infection prevention and control; -Protecting Resident rights in nursing facilities; -Safe transfers; -Perineal Care check list; -Dementia care: managing challenging behaviors; -Emergency Disaster Preparedness; -Electronic Medical Record charting; -Annual education includes all the new hire training plus the topics of corporate compliance,…

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

Based on observation, interview, and record review, facility staff failed to thoroughly investigate and document bruises of unknown origin for one resident (Resident #15) out of one sampled residents as directed by the facility policy. The facility census was 55. 1. Review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated September 2022, showed all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, states, and federal agencies and thoroughly investigated by facility management. Review showed if resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Review showed: -The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: -The state licensing/certification agency…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility staff failed to develop a comprehensive person-centered care plan to meet the resident's medical, nursing, mental and psychosocial needs for four residents (Resident #18, #29, #40 and #47) out of five sampled residents. The facility's census was 55. 1. Review of the facility's Care Plans Goals and Objectives policy, dated April 2009, showed: -Care plan goals and objectives are derived from information contained in the resident's comprehensive assessment and are resident oriented, behaviorally stated, are measurable and contain timeframes to meet the resident's needs in accordance with the comprehensive assessment; -Goals and objectives are reviewed and/or revised when there has been a significant change in the resident's condition, when the desired outcome has not been achieved, when the resident has been readmitted to the facility from a hospital/rehabilitation stay and at least quarterly. 2. Review of Resident #18's Quarterly Minimum Data Set (MDS), 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, facility staff failed to obtain a timely advanced directive who received Cardiopulmonary Resuscitation (CPR) when he/she elected to be a Do Not Resuscitate (DNR - indicates that, in case of respiratory or cardiac failure, the resident has directed that no cardiopulmonary resuscitation or other life-sustaining treatments or methods are to be used) and failed to document residents' code status consistently as a DNR for one resident (Resident #1). The facility census was 62. 1. Review of the facility's Advance Directives policy, revised [DATE], showed advanced directives will be respected in accordance with state law and facility policy. The resident has the right to refuse treatment. A resident will not be treated against his/her wishes. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. The plan of care for each resident will be consistent with his/her documented treatment preferences. 2.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to provide care to meet the hygiene needs for four residents (Resident #1, #2, #3 and #4) out of five sampled residents when staff did not provide nail care and assist with facial hair. The facility census was 64. 1. Review of the facility's Activities of Daily Living (ADLs), Supporting policy, dated March, 2018, showed staff were directed as follows: -Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to care out ADL; -Resident who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. -Residents will be provided with care, treatment and services to ensure that their ADLs do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable; -Appropriate care and services will be provided for resident who are…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility staff failed to develop and implement a comprehensive person-centered care plan for one resident (Resident# 2), and failed to update care plans at least quarterly in conjunction with the required Minimum Data Set ((MDS) a federally mandated assessment instrument), to provide interventions to meet individual needs for two residents (Resident #1 and #3) out of three sampled residents. The facility census was 68. 1. Review of the facility's Goals, Objectives, and Care Plans policy, revised April 2000, showed staff are directed as follows: -Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence; -Goals and objectives are entered onto the resident's so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved; -Goals and objectives are reviewed and/or revised at least quarterly. 2. Review of Resident #1's quarterly MDS,…

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, facility staff failed to ensure residents' privacy were protected, when six resident's (Resident's #2, #3, #7, #8, #9 and #16) out of 16 sampled residents, medical information were face up on the nurse station desks, in a public area visible by other residents and visitors to the facility. Facility census was 71. 1. Review of the facility's policy titled Confidentiality of Information and Personal Privacy, dated October 2017, showed the facility will strive to protect the resident's privacy in regards to his/her: accommodations; medical treatment; and personal care. Access to resident personal and medical records will be limited to authorized staff and business associates. 2. Observation on 09/25/24 at 10:27 A.M. and 10:31 A.M., showed the nurses station desk unattended with the resident report sheet face up, and contained Resident #2, #3, #7, #8, #9 and #16 code status, date of birth , allergies, and diagnoses. Observation showed multiple resident near the nurses station. 3. Observation on 09/25/24 at 10:33 A.M., showed Licensed Practical Nurse…

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 interviews and record reviews, facility staff failed to report allegations of misappropriation of money for two residents (Residents #1 and #5) of 16 sampled residents to other officials in accordance with State law (including the State survey and certification agency). The facility census was 71. 1. Review of the facility's policy titled Abuse and Neglect , dated March 2018, showed the management and staff, with physician support, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations. 2. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 08/27/24, showed staff assessed the resident as moderate cognitive impairment. During an interview on 09/25/26 at 11:42 A.M., the resident said he/she had $3,000 dollars in his/her wallet, in the drawer when he/she went to sleep and the next day it was gone. The resident said the money went missing two days…

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 staff failed to document they provided the physician ordered wound treatments for one resident (Resident #14) of 16 sampled residents. The facility census was 71. 1. Review of the facility's policy titled Administering Medications, dated April 2019, showed the Director of Nursing (DON) supervises and directs all personnel who administer medications and/or have related functions. Medications are administered in accordance with prescriber orders, including any required time frame. Topical medications used in treatments are recorded on the resident's treatment record (TAR) 2. Review of Resident #14's Significant Change Minimum Data Set (MDS) a federally mandated assessment tool, dated 07/24/24, showed staff assessed the resident as follows: -Cognitively intact; -Did not refuse care; -Incontinent of urine; -Three stage three pressure ulcers (a full-thickness tissue loss that extends into the fat tissue below the skin). Review of the resident's care plan, dated 05/03/24, showed staff assessed the resident with stage three pressure ulcer…

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

Based on observation, interview, and record review, facility staff failed to ensure medications were monitored and stored in a safe and effective manner. The facility census was 71. 1. Review of the facility's policy titled Administering Medications, dated April 2019, showed during the administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. Observation on 09/25/24 at 10:12 A.M., showed an unlocked medication cart, on the rehabilitation hall unattended. Resident #6 propelled self in wheelchair past unlocked medication cart. During an interview on 09/25/26 at 10:16 A.M., Certified Medication Technician (CMT) C said he/she forgot to lock the medication cart. The CMT said he/she gave a medication, then went off the hall to check on showers and forgot to lock the cart. During an interview on 09/26/24 at 11:39 A.M., DON said staff should lock the medication cart,…

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 staff failed to store food in a manner to prevent potential contamination and out-dated use. Facility staff failed to maintain the kitchen equipment and surfaces in a sanitary manner to prevent the growth of bacteria and cross-contamination. Facility staff failed to maintain and serve food at temperatures adequate to prevent food borne illness. The facility staff failed to ensure the ice machine, used to supply ice to residents, drained through an air gap to prevent cross-contamination. These failures have the potential to affect all residents. The facility census was 72. 1. Review of the facility's policies showed the facility did not provide a policy for food dating and storage. 2. Observation on 06/04/24 at 9:00 A.M., showed the reach in refrigerator contained a plastic pour container labeled as Italian with a use by date of 5/20/24 and an eight quart plastic container labeled as ham which was dated 5/12/24. 3. Observation 06/04/24 at 9:05 A.M., showed the reach in freezer contained: -An unlabeled, undated bag 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, facility staff failed to provide the services of a Registered Nurse (RN), for at least eight hours per day, seven days a week. The facility census was 72. 1. Review of the facility's policies showed the facility did not provide a policy for RN coverage. Review of the facility's RN staff schedule, dated March 2024, showed the facility did not have an RN in the building on: -Saturday 03/02/24; -Sunday 03/03/24; -Saturday 03/09/24; -Saturday 03/10/24; -Saturday 03/23/24; -Saturday 03/24/24; -Saturday 03/30/24; -Saturday 03/31/24. Review of the facility's RN staff schedule, dated April 2024, showed the facility did not have an RN in the building on the following dates: -Saturday 04/06/24; -Sunday 04/07/24; -Saturday 04/13/24; -Sunday 04/14/24; -Saturday 04/20/24; -Sunday 04/21/24; -Sunday 04/28/24. Review of the facility's RN staff schedule, dated May 2024, showed the facility did not have an RN in the building on the following dates: -Saturday 05/04/24; -Sunday 05/05/24; -Saturday 05/11/24; -Sunday 05/12/24; -Saturday 05/18/24; -Sunday 05/19/24;…

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

Based on observation, interview, and record review, facility staff failed to store and label medications in a safe an effective manner when staff did not document the open date on medication in the medication cart and failed to discard expired medications. The facility census was 72. 1. Review of the facility's policy titled, Administering Medications, revised 04/2019, showed the expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. 2. Observation on 06/04/24 at 8:16 A.M., showed the rehabiliation hall medication cart contained: -One bottle of Fish Oil, opened and undated; -Two bottles of acetaminophen, opened and undated; -One bottle of omeprazole (used to treat hearburn), opened and undated; -One bottle of Ibuprofen, opened and undated. Observation on 06/04/24 at 8:35 A.M., showed the 300 hall medication cart contained: -One bottle of magnesium oxide (mineral supplement), opened and undated; -One bottle of ferrous sulfate, opened and undated with an expiration date of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to document collaboration of care with hospice providers for development and implementation of a coordinated plan of care and communication between the facility and local hospice provider for two (Resident #40 and #59) out of two sampled residents who received hospice services. The facility census was 72. 1. Review of the facility's Nursing Facility Hospice and Respite Care Services Agreement, dated March 11, 2020, showed: -Hospice will develop, at the time a resident of the facility is admitted into Hospice's program, a Plan of Care for the management and palliation of the resident's terminal illness. The Plan of Care will be updated as often as the patient condition requires, but no less frequently then every 15 calendar days; -Quality Improvement: The Hospice and Facility representatives shall document and keep written records of all such communications and shall document that the services provided are furnished in accordance with the terms of this…

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, interviews, and record review, the facility staff failed to ensure the ice bin drained through an air gap. Facility staff failed to maintain the ceiling over the food preparation and service area in a clean and sanitary manner. This had the potential to affect all facility residents. The census was 80. 1. Review of the facility's policies showed the facility did not have a policy which addressed the inspection and maintenance of the ice machine. Observation on 1/26/23 at 1:00 P.M., showed the ice machine, located in the kitchen, did not drain through an air gap. Observation also showed the ice machine drain lay on top of the floor drain, and the ice machine drain and the floor drain were covered in a black sludge type substance. During an interview on 1/26/23 at 1:00 P.M., the maintenance director said he is responsible to inspect and maintain the ice machine according to regulations. He said he checks the ice machine every month to ensure it is level and functioning, but he does not look underneath the ice machine at the drain pipe. He said he was not aware…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to maintain the dignity of three residents (Residents #34, #51 and #54), when staff failed to clean the resident's fingernails prior to meals, in which the residents ate with their fingers, and referred to one resident (Resident #8), who required assistance at meal time, as a Feeder. Additionally staff failed to maintain the dignity of one resident (Resident #47), when staff provided care to the resident with the privacy curtain open and left the door open with a resident exposed for one resident (Resident #48). The facility census was 80. Review of the facility's Assistance With Meals Policy, revised July of 2017, showed: -Residents shall receive assistance with meals in a manner that meets the individual needs of each resident; -Residents who cannot feed themselves, will be fed with attention to safety, comfort and dignity; -Avoiding the use of labels when referring to residents (e.g.,feeders); -All employees who provide 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 record review and interview the facility staff failed to complete a baseline care plan within 48 hours of admission, review the information with the resident/responsible party, or provide a copy to the resident/responsible party for seven residents (Resident #5, #46, #54, #67, #80, #82, and #327). The facility census was 80. 1. Review of the facility's policy, Care Plans - Baseline, revised December 2016, showed: -A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission; -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 summary of the resident's medications and dietary instructions; -Any services and treatments to be administered by the facility and personnel acting on behalf of the facility; -Any updated information based on the details of the comprehensive care plan, as necessary. 2. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed ensure four dependent residents (Resident #29, #38, #58, and #64) received the necessary services to maintain good grooming and personal hygiene when staff failed to maintain the residents' facial hair and nails, failed to ensure residents wore clean clothes and failed to provide dental services. The facility census was 80. Review of the facility's Activities of Daily Living (ADL), Supporting Policy, revised March 2018, showed: -Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs); -Residents who are unable to carry out activities of daily living independently will received the services necessary to maintain good nutrition, grooming and personal and oral hygiene; -Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to securely store smoking materials (lighters and cigarettes) for two residents (Resident #58 and #67). Additionally, staff failed to document neurological checks (assessment completed to determine if the nervous system is impaired) for two residents (Resident #29 and #38), failed to implement a fall intervention for one resident (Resident #38) after a fall, and failed to ensure a fall mat was used for one resident (Resident #52). The facility census was 80. 1. Review of the facility's Smoking Policy - Residents, revised July 2017 showed: -Residents who have independent smoking privileges are permitted to keep cigarettes, e-cigarettes, pipes, tobacco, and other smoking articles in their possession. Only disposable safety lighters are permitted. All other forms of lighters, including matches, are prohibited; -Residents without independent smoking privileges may not have or keep any smoking articles, including cigarettes, tobacco, etc.,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to ensure three residents (Resident #5, #32 and #51) had an appropriate indication for the use of anti-psychotic medications, and failed to document resident behaviors and the efficacy of the antipsychotic medications. Additionally, staff failed to re-evaluate one resident's (Resident #51's) behaviors and notify the physician before administering an antipsychotic medication that had been discontinued and as part of a Gradual Dose Reduction (GDR) attempt. The facility census was 80. 1. Review of the facility's Antipsychotic Medication Use policy, revised December 2016, showed: -Antipsychotic medications may be considered for residents with Dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed; -Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are…

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

Based on observation, interview, and record review, facility staff failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, when staff failed to use appropriate hand hygiene during the provision of care and failed to use appropriate infection control procedures during catheter care for one resident (Resident #52) and during incontinence care for one resident (Resident #55). The facility staff also failed to provide wound care in a manner to reduce the risk of infection for one resident (Resident #45). Additionally, staff failed to follow their facility policy to ensure three employees (Registered Nurse (RN) P, [NAME] Q and Housekeeper R), out of seven sampled employees, were screened for Tuberculosis (TB), (disease caused by bacteria called Mycobacterium tuberculosis, that usually attacks the lungs). The facility census was 80. 1. Review of the facility's Standard Precautions policy, dated 2007, showed: -Standard…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to conduct regular inspections of bedrails as part of a regular maintenance program by failing to measure and assess all possible entrapment zones for five residents (Residents #2, #20, #35, #58, and #64). The facility census was 80. Review of the United States Food and Drug Administration (FDA) document entitled, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment dated March 10, 2006, showed 413 people died as a result of entrapment events in the United States. Further review showed those among the most vulnerable for these entrapment type events are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. Review of the FDA document entitled, Practice Hospital Bed Safety, dated February 2013 identifies seven different potential, zones of entrapment. This guidance characterizes the head, neck, and chest as key body parts that are at risk 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, facility staff failed to provide appropriate treatment and services to prevent further decrease in range of motion (ROM), movement of a joint, for one resident (Resident #52), who had a contracture to the left wrist. The facility census was 80. Review of the policies provided by the facility showed it did not contain a policy for ROM. 1. Review of Resident #52's Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment tool, showed staff assessed the resident as: -Severe Cognitive Impairment; -Did not have behaviors; -Did not reject care; -No impairment to upper extremities (shoulder, elbow, wrist, hand); -Diagnoses of right hip fracture, peripheral vascular disease (PVD), disease that causes decreased circulation to extremities, Stroke, hemiplegia or hemiparesis (Paralysis or mild to severe weakness to one side), and cognitive communication deficit (difficulty with speaking and understanding). Review of the resident's Electronic Health Record (EHR), showed Medical Diagnoses 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, facility staff failed to provide appropriate care and services for one resident (Resident #52) with an indwelling urinary catheter (a drainage tube that is inserted into the urinary bladder, left in place, and is connected to a drainage bag) when staff failed to obtain a physician's order for the use and care of the catheter, failed to ensure the resident's catheter drainage bag was kept off the floor, and failed to provide catheter care in a manner to prevent the spread of infection. The facility census was 80. Review of the facility's Catheter Care, Urinary Policy, dated September 2014, showed staff are directed to: -The purpose of the procedure is to prevent catheter-associated urinary tract infections (CAUTIs); -Be sure the catheter tubing and drainage bag are kept off the floor; -Place clean equipment on the bedside stand or overbed table; -Use a washcloth with warm water and soap to cleanse the genitals. Use one area of the washcloth for each downward, cleansing stroke. Change position of the washcloth with each downward…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to obtain physician orders for the use of Continuous positive airway pressure (CPAP), a non-invasive ventilation machine that involves the administration of air usually through the nose by an external device at a predetermined level of pressure, for two residents (Resident #5 and #328). Additionally, staff failed to implement a comprehensive person centered care plan for the use of CPAP for one resident (Resident #5). The facility census was 80. Review of the policies provided by the facility showed they did not contain a policy for CPAP use. 1. Review of Resident #5's 5 Day Prospective Payment System (PPS) Minimum Data Set (MDS), dated [DATE], showed staff assessed the resident as: -admitted [DATE]; -Cognitively Intact; -Did not reject care; -Independent with personal hygiene; -Did not use a CPAP; -Received no respiratory therapy; -Diagnoses of viral pneumonia, heart failure, septicemia, anxiety, asthma, Chronic Obstructive Pulmonary…

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.