Aspire Senior Living Jonesburg

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to consistently document the code status as Do Not Resuscitate (DNR) or Full Code - Cardiopulmonary resuscitation ((CPR) an emergency procedure that combines chest compressions and rescue breathing to restart a person's breathing and heartbeat) on the face sheet, and/or Physician Order Sheet (POS) for five residents (Resident #20, #25, #34, #42 and #53) out of 24 sampled residents. The facility census was 59.1. Review of the facility policy titled Basic Life Support/CPR, dated [DATE], showed the purpose is to ensure this facility is able to, and does provide, emergency basic life support when needed, including CPR, to any resident requiring such care prior to the arrival of emergency medical personnel in accordance with related physician orders, such as DNR and the resident's advance directives. Potential rescuers will initiate CPR, in addition to calling 911, unless a valid DNR order is in place; and the facility staff must provide basic life support,…

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 signed consent for bed rail use and failed to assess three residents (Resident #2, #5 and #15) out of four sampled, for bed rail use. The facility census was 59. 1. Review of the facility's policy titled Bed Rail, dated 01/30/2024, showed bed rails are adjustable metal or rigid plastic bars that attached to the bed. Examples of bed rails include grab bars, assist bars, side rails, and safety rails. Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. The Facility should maintain evidence that is has provided sufficient information so that the resident or resident representative could make an informed decision. The Facility will assess the resident's need for bed rails, documentation in the resident's record will reflect this assessment and related information. 2. Review of Resident #2's Significant Change Minimum Data Set (MDS), a federally…

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 complete entrapment assessments and regular inspections of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for four residents (Residents #2, #3, #5, and #15) out of four sampled residents. The facility census was 59.1. Review of the facility's policy titled Bed Rail, dated 01/30/24, showed assess the resident for risk of entrapment from bed rails prior to installation. Ensure the bed's dimensions are appropriate for the resident's size and weight. Inspect and regularly check the mattress and bed rails for areas of possible entrapment. Check bed rails regularly to make sure they are still installed correctly as rails may shift or loosen over time. The facility must also conduct routine preventive maintenance of beds and bed rails to ensure they meet current safety standards and are not in need of repair. After installation of bed rails; it is expected that 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 record review and interview, facility staff failed to report to the Department of Health and Senior Services (DHSS) within the two-hour required timeframe a resident to resident altercation between two residents (Resident #1, and Resident #2) when Resident #1 slapped Resident #2. The facility census was 56. 1. Review of the facility's abuse, neglect, exploitation or mistreatment policy, dated 1/30/24, showed the purpose of the policy is to ensure all alleged violations related to mistreatment, exploitation, neglect, or abuse are thoroughly investigated and reported to the proper authorities within the required time frames. All alleged violations of abuse, neglect, exploitation or mistreatment are reported immediately, but not later than two hours after the allegation is made to the administrator of this facility and to other officials to include State Survey Agency and adult protective services where state law provides for jurisdiction in long term care facilities. 2. Review of the facility's…

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

Based on record review and interview, facility staff failed to ensure one resident (Resident #1) remained free from verbal and physical abuse when Certified Nursing Assistant (CNA A) threatened Resident #1 with rough treatment. The facility census was 60. The administrator was notified on 12/24/24 of past Non-Compliance which occurred on 12/24/24. On 12/24/24, staff notified the administrator they witnessed CNA A telling Resident #1 he/she would manhandle the resident if the resident did not cooperate with care. Staff immediately suspended CNA A, assessed the resident for injuries, and notified the required parties and agencies. The administrator terminated CNA A on 12/26/24. The administrator in-serviced all staff, on abuse and neglect policies and procedures by 12/30/24. 1. Review of the facility's Abuse, Neglect, and Misappropriation Policy, dated 1/30/24, showed the purpose is to ensure each resident's right to be free from abuse, neglect, and corporal punishment of any type by anyone. Review showed abuse is a willful infliction of injury, unreasonable confinement, intimidation,…

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 an appropriate emergency discharge notice for one resident (Resident #1) and failed to allow Resident #1 to return to the facility when the resident was ready for discharge from the hospital. The facility census was 62. 1. Review of the facility's Transfer and Discharge policy, undated, showed staff were directed to: -Ensure resident rights are protected when the facility can no longer provide care or services needed; -The facility must notify the resident at least thirty days prior to the anticipated transfer; -A transfer or discharge will not be done except when the safety of individuals in the facility is endangered, due to the clinical or behavioral status of the resident, and as documented/confirmed by a physician; -Preparation and orientation of the resident is essential to ensure safe and orderly transfer or discharge from the facility. Sufficient preparation means that the facility informs the resident where he/she is going and takes steps under its control to ensure safe transportation. The facility 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, facility staff failed to provide a comfortable and homelike environment for residents, when staff failed to maintain walls, floors, lighting, and sink countertops in good repair. The facility census was 60. 1. Review of the facility's Physical Environment policy, undated, showed: -The facility will provide a safe, functional, sanitary and comfortable environment for residents, staff and the public; -The facility must be designed, constructed, equipped, and maintained to protect the health and safety of residents, personnel and the public; -Resident rooms must be designed and equipped for adequate nursing care, comfort, and privacy of residents; -Maintain all mechanical, electrical, and patient care equipment in safe operating condition; -The policy did not contain direction or guidance to report facility repairs or routine inspection of the facility. 2. Observation on 08/20/24 at 10:55 A.M., showed occupied resident room [ROOM NUMBER] on the secured unit with 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 provide written information to the resident and/or the resident's representative of the bed hold policy for three residents (Resident #27, #50, and #163) of three sampled residents who discharged to the hospital. The facility census was 60. 1.Review of the facility's Bed Hold policy, undated, showed the following: -The facility will notify all residents, and/or their representative of the bed hold policy guidelines upon admission to the facility, at the time of transfer to the hospital or leave and at the time of non-covered therapeutic leave; -If the resident or representative wants to hold the bed, a signed authorization of the bed hold selection notice must b e obtained with each physician approved hospitalization; -Signed authorization must be received within 48 hours of the transfer or leave, if it occurs during the week and by the first business day following the transfer if it occurs on a weekend or holiday. 2. Review of Resident #27's medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 three residents (Resident #41, #44, and #164) out of ten sampled residents. The facility census was 60. 1. Review of the facility's Care Plan Comprehensive policy, dated March 2015, showed: -The comprehensive care plan will be based on a thorough assessment that includes, but is not limited to, the Minimum Data Set (MDS), a federally mandated assessment tool; -Assessment of each resident is ongoing process and the care plan will be revised as changes occur in the resident's condition; -The interdisciplinary team is responsible for the periodic review and updating of care plans when a significant change has occurred, at least quarterly, and when changes occur that impact the resident's care; -A well developed care plan will be oriented to assessing and planning for care to meet the resident's medical, nursing,…

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 (8) consecutive hours per day, seven days a week. The facility census was 60. 1. Review of the Facility Assessment, reviewed July 2024, showed the facility to have an RN at least 8 hours per day, seven days a week. Review of the facility's Nurse Staffing, dated 08/01/24 through 08/22/24, showed staff did not provide an RN eight hours a day on 8/3/24, 8/4/24, and 8/17/24. During an interview on 08/23/24 at 8:38 A.M., RN K said there are times when there is not an RN in the building and has been times that the only other RN aside from him/her was the Director of Nursing (DON). He/She said the DON tries to keep RN coverage on duty but one is not always available. RN K said he/she fills in when he/she can on the weekends. During an interview on 08/23/24 at 9:26 A.M., the DON said he/she tries to keep RN coverage of 8 hours everyday to include the weekends, but just doesn't always have one available. He/She said a RN has been hired to work every other weekend.…

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 destroy medications in a timely manner for seven residents (Resident #1, #6, #20, #21, #23, #25, #33, and #37). Staff failed to discard expired medications from one out of two sampled medication carts. Failed to ensure medications were stored in a safe and effective manner, by not ensuring medications were properly labeled and contained in their original package until time of administration on two of two sampled medication carts. The facility census was 60. 1. Review of the facility's Medication Storage policy, dated March 2015, showed: -Medications must be stored in the container in which they were received; -No discontinued, outdated, or deteriorated drugs or biologicals may be retained for use. All such drugs must be returned to the issuing pharmacy or destroyed in accordance with established guidelines. Review of the facility's Medication Destruction policy, revised March 2015, showed: -All medications not returned to the issuing pharmacy will be destroyed; -Two licensed nurses or one licensed nurse 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.

Based on interview and record review, the facility staff failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate qualifications, when the facility did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. This failure has the potential to affect all residents. The facility census was 60. 1. Review of the facility's Dietary Supervisor (DS) position description, undated, showed the minimum requirements for the position included Certified Dietary Manager Certification (CDM) or equivalent credential required. During an interview on 08/20/24 at 11:03 A.M., the DS said he/she had been the DS for about three years. The DS said he/she started the CDM course a couple of years ago, but never finished. The DS said he/she had not completed other dietary management training. The DS said he/she was aware of the requirement to complete the CDM or equivalent certification. The DS said the dietician comes to the facility about every other month. During an interview on 08/22/24 at 11:45 A.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.

Based on observations, interviews and record review, facility staff failed to close the computer screens from view which showed resident information when left unattended for two (Resident #44 and #46) out of five sampled residents and on two medication carts. The facility census was 60. 1. Review of the facility's Protecting, Promoting and Ensuring Resident Rights policy, dated 1/30/24, showed the resident has the right to personal privacy and secure confidential personal and medical records. 2. Observation on 08/21/24 at 2:33 P.M., showed Registered Nurse (RN) J entered Resident #44's room and did not minimize or lock the compter screen on the treatment cart. Observation showed the residents medical information displayed. Observation on 08/21/24 at 2:51 P.M., showed RN J entered Resident #46's room. and did not minimize or lock the compter screen on the treatment cart. Observation showed the residents medical information displayed. During an interview on 08/21/24 at 3:12 P.M., RN J said staff should close the screen or lock it when stepping from the cart to maintain privacy 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 observation, interview and record review, facility staff failed to post the required nurse staffing information in an manor easily accessible for residents and visitors, and failed to include the required data in the posting. The facility census was 60. 1. Review of the facility's Nurse Staffing Information policy, undated, showed: -The facility must post the following information daily: facility name, current date, the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: Registered Nurse (RN), Licensed Practical Nurses (LPN) and Certified Nurse Aides (CNA), and the resident census; -The facility must post the nurse staffing data as specified above daily at the beginning of each shift; -Must be posted in a prominent place readily accessible to residents and visitors. 2. Review of the facility's Staff Hour Posting, dated July 1, 2024, showed staff did not document the census or document actual hours worked for 28 of 31 days in July 2024. 3. Review of the facility's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, facility staff failed to use appropriate infection control procedures to prevent or reduce the risk of spreading bacteria, when staff failed to wash or sanitize their hands in between glove changes when providing wound care for four residents (Resident #1, #2, #3, and #4) of four sample residents. The facility census was 62. 1. Review of the facility's policy titled, Wound Care and Treatment, dated 03/2015, showed staff were directed to do the following: -Hand washing must be done as outlined in the guidelines; -Put gloves on; -Remove the soiled dressing and place in the trash bag; -Remove the gloves and discard in the bag; -Wash your hands and put on clean gloves; -Clean the wound according to the order; -Remove gloves, place in trash bag, and put on a clean pair of gloves; -Apply clean dressing as ordered; -Wash your hands. 2. Review of the Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 01/03/24, showed the staff assessed the resident…

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

Based on record review and interview, the facility failed to establish and maintain a process to follow generally accepted accounting principles to reconcile the Resident Trust Fund Account monthly. The facility census was 59. 1. Review of the facility's policies showed the facility staff did not provide a policy for reconciling the resident trust fund. Review of reconciled resident trust bank statement balances and resident trust fund balance reports for the period from July 2022 through June 2023 showed staff did not reconcile the accounts at the end of each month. Further review showed reconciled bank statement and resident trust balances as follows: -July 22 Reconciled bank balance was $65,746.10, Trust balance was $65,218.30; -August 22 Reconciled bank balance was $69,661.05, Trust balance was $68,948.20; -September 22 Reconciled bank balance was $64,744.57, Trust balance was $64,702.08; -October 22 Reconciled bank balance was $65,907.8, Trust balance was $65,865.37; -November 22 Reconciled bank balance was $65,048.95, Trust balance was $65,006.46; -December 22 Reconciled bank…

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 staff failed to document residents' code status consistently, Do Not Resuscitate (DNR) or Full Code (Resuscitate refers to cardiopulmonary resuscitation-CPR) for three residents (Resident #23, #31, and #48). The facility census was 59. 1. Review of the facility's Advance Directive Policy, dated [DATE], showed: -Upon admission of a resident, the social services designee will inquire of the resident, and/or his/her family members, about the existence of any written advanced directives; -Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record under the advanced directive tab. 2. Review of Resident #23's Face Sheet in their Electronic Medical Record (EMR) showed staff documented the resident as full code status. Review of the resident's Outside of the Hospital DNR form showed the resident revoked his/her DNR status on [DATE]. Review of the resident's Physician Order Sheet (POS), dated…

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 staff failed to ensure residents had a DA-124 Level I screen (used to evaluate for the presence of psychiatric conditions to determine if a preadmission screening/resident review (PASARR) Level II screen is required) completed as required, for three residents (Residents #21, #48, and #52). The census was 59. 1. Review of the facility's policies showed the facility did not provide a policy for PASARR screening. 2. Review of Resident #21's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/15/23, showed the following: -Date of admission 6/1/21; -No screening information regarding PASARR, Level II PASARR, or conditions related to serious mental illness/intellectual disabilities/related conditions; -Diagnoses included major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), bipolar…

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 staff interview and record review, facility staff failed to meet professional standards of care when nursing staff did not count scheduled narcotics at change of shift when the medication cart changed from one staff member to another. The facility census was 59. 1. Review of the facility's Scheduled Medications policy, dated March 2015, showed: -Scheduled medications will have disposition records that are in a binder on the medication cart or area instructed by the Director of Nursing (DON); -All schedule II, III, IV, V medications must be counted (comparing number of pills to disposition record) at every change of shift by two Certified Medication Technician (CMT)s, or one CMT and one licensed nursing staff; Both personnel must sign verification of correct count for Schedule II, III, IV and V medications; -If, at any time, the count is incorrect, the CMT must notify licensed nursing staff, who will call the DON or designee for instruction. Review of the facility's Narcotic Count policy, dated March 2015, showed: -One Registered Nurse (RN), Licensed Practical Nurse (LPN) or…

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 assist seven out of fifteen sampled dependent residents (Resident #5, #10, #21, #28, #41, #56 and #57) with grooming and bathing as needed. The facility census was 59. 1. Review of the facility's Activities of Daily Living (ADL) policy, dated March, 2015, showed the policy did not give staff direction for bathing and grooming. 2. Review of Resident #5's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 6/17/23 , showed facility staff assessed the resident as: -Cognitively intact; -Totally dependent on two plus persons for transfers; -Totally dependent on two plus persons for toilet use: -Required physical help of one person for bathing. Review of the resident's care plan, dated 5/25/23 showed the goal for the resident was to not exhibit complications of prolonged immobility and would be kept clean, dry, odor free and well groomed. Review of the resident's shower sheets between 5/1/23 and 7/13/23 showed staff…

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, resident and staff interview and record review, facility staff failed to ensure the resident environment remained free of accident hazards when facility staff failed to ensure electronic cigarettes were kept secure for one resident (Resident #10), failed to ensure hazardous chemicals were stored in a safe manner not accessible to residents, and failed to ensure one resident (Resident #23) took all medications prior to leaving the resident's room, leaving two potassium pills on the resident's bedside table. The facility census was 59. Review of the facility's policy Resident Rules and Regulations, undated, showed the following: - For safety reasons, the resident and any visitor to this facility is hereby advised not to smoke cigars, cigarettes, and vapes except under supervision and/or in designated smoking areas. Residents may not retain matches, lighters, or electronic cigarettes/chargers. 1. Review of Resident #10's quarterly Minimum Data Set (MDS) a federally mandated assessment tool,…

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 safe and effective manner in one of one medication storage rooms, and one of two medication storage carts. The facility census was 59. 1. Review of the facility's Medications, Storage Of Policy, dated March, 2015, showed staff were directed as follows: -No discontinued, outdated, or deteriorated drugs or biologicals may be retained for use. All such drugs must be returned to the issuing Pharmacy or destroyed in accordance with established guidelines; -Medications must be stored in the container they were received in. 2. Observation on 7/13/23 at 8:40 A.M., showed the medication storage room contained one Medline lubricating jelly box of 144 packets with an expiration date of June 2023. Observation on 7/13/23 at 9:00 A.M., showed the 500 hall medication cart contained the following: -One round yellow tablet; -One oval shaped blue tablet; -One orange round tablet; -One oval yellow tablet. 3. During and interview on 7/14/23 at 9:05 A.M., Licensed Practical Nurse (LPN) C said all…

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 staff failed to maintain and follow current guidance and procedures for immunizations of residents against pneumococcal pneumonia (infection caused by bacteria) in accordance with national standards of practice and failed to offer, administer, and document the administration or refusal of the pneumococcal immunization for two of eight residents (Residents #3 and #41) sampled. The facility census was 59. 1. Review of the facility's policies showed staff did not provide a resident immunization policy. Review of the U.S. Department of Health and Human Services Centers for Disease Control and Prevention (CDC), pneumococcal and influenza vaccine timing for adults, dated 2023, showed the following: -Four types of pneumonia vaccines are acceptable for adults 65 years or older. PCV13: 13-valent pneumococcal conjugate vaccine (Prevnar13), PCV15: 15-valent pneumococcal conjugate vaccine (Vaxneuvanc), PCV20: 20-valent pneumococcal conjugate vaccine (Prevnar20), and PPSV23:…

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, facility staff failed to implement policies and procedures for reporting when staff failed to notify local law enforcement agency for a potential theft of pain medication and failed to notify the State Survey agency for a resident to resident altercation after Resident #48 punched Resident #46 in the shoulder. The facility census was 59. 1. Review of the facility's Abuse policy, dated November 2017, showed: -The nursing home Administrator or designee will report abuse to the state agency per State and Federal requirements; -The facility will ensure that any reasonable suspicion of crimes committed against a resident of this facility will be reported to the appropriate Law Enforcement Agency as established by section 6703(b)(3) of the Patient Protection and Affordable Care Act of 2010. When there is reasonable suspicion that a crime has occurred, then in addition to reporting the allegation of abuse to the State Survey Agency, the incident must be reported to the local law enforcement; -The facility will adhere to reporting time frames as…

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

Based on observation, interviews and record review facility staff failed to ensure one resident (Resident #3) who received tube feeding (supplies liquid nutrition) through a gastrostomy tube (G-tube, a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) received the appropriate treatment and services. The census was 59. 1. Review of the facility's Enteral Nutritional Therapy (Tube Feeding) policy, dated March 2015 showed staff are instructed to check the pump flow rate every shift and clear pump at the end of shift to document volume infused. Review of Resident #3's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 4/06/23, showed facility staff assessed the resident as: -Severe cognitive impairment; -Totally dependent for feeding and hygiene; -Diagnosis included unspecified intellectual disabilities, dysphagia (difficulty swallowing) and aphasia (brain disorder where a person has trouble speaking or understanding other people speaking). Review of the resident's Physician's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility staff failed to review, revise and develop individualized interventions for one resident (Resident #48) who had behaviors and failed to provide the required Nurse Aide dementia training in the past 12 months. The facility census was 59. 1. Review of the facility assessment dated [DATE], showed: -22 Residents have behavioral health needs; -All staff will be trained on hire and annually regarding care and management of persons with dementia; -Certified Nurse Aides will be trained on hire and annually regarding dementia management training. Review of the facility's Census and Conditions dated 7/11/23 showed: -29 residents with dementia or Alzheimer's Disease; -22 residents with behavioral healthcare needs. Review of the facility's Care Plan Comprehensive policy, dated March 2015 showed: -The Interdisciplinary Team (IDT) with input from the resident, family and/or legal representative will develop and maintain a comprehensive care plan for 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.