Clara Manor Nursing Home

Deficiency Text Not Available

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Refer to F622 Event ID 66SW12 Based on interview and record review, the facility failed to plan, coordinate, and provide a safe and appropriate discharge when the facility initiated an immediate discharge for one sampled resident (Resident #76) out of 36 sampled residents. The resident's discharge notice stated the transfer location was Facility B, however, the resident was transported to the hospital via Emergency Medical Services. Facility B was unaware the resident was to be discharged to them. The facility census was 86 residents. Review of the facility's Discharge and Transfer Resident policy, dated 12/21/24, showed: -The purpose of the policy was to ensure the appropriate procedure for transferring and discharging a resident. -All residents who were discharged out of the facility under any circumstance was given an order from the attending physician. -Provide written instruction with verbal explanation regarding care, treatment, use of medications or devices to the resident upon discharge. -Order 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 Refer to F623 Event ID 66SW Based on interview and record review, the facility failed to provide an appropriate discharge notice for one sampled resident (Resident #76) out of 36 sampled residents, when the Discharge Notice issued to the resident had incorrect contact information for the Ombudsman, incorrect contact information in order for the resident to appeal the discharge, and did not have the correct discharge location listed on the notice. The facility census was 86 residents. Review of the facility's Discharge and Transfer Resident policy, dated 12/21/24, showed: -The purpose of the policy was to ensure the appropriate procedure for transferring and discharging a resident. -Involuntary discharges must: --Be reviewed by the Safety Committee. --The physician shall be consulted. --Can be immediate in the case of emergency due to: ---The safety of individuals at the facility was endangered due to clinical or behavioral status of the resident. --Issue a discharge notice letter to the resident, including 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 Refer to F740 Event ID 66SW12 Based on observation, interview and record review, the facility failed to effectively manage behaviors by not providing appropriate behavior interventions for one sampled resident (Resident #76) when the resident physically assaulted and injured Resident #69 by hitting him/her in the face causing pain, swelling, and redness. The facility census was 86 residents. Review of the facility's Behavior Management Program, undated, showed: -A behavior symptom was defined as an indication or characteristic of a negative physical or psychosocial outcome which may have resulted in disturbing of others. -A behavior could also inhibit the resident in attaining or maintaining his/her highest practical well-being. -The purpose of the policy was to promote a healthy environment that provided comfort to all residents. -The staff may detect early changes in mental or psychosocial status for appropriate interventions, which included: medication regimen, activities, counseling, visits (not specified)…

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

Based on interview and record review, the facility failed to ensure the Dietary Manager (DM) met one of the qualifications for a Certified Dietary Manager (CDM) by having a national certification for food service management and safety, from a national certifying body, or at least an associate's degree in food service management or in hospitality, or had 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management. This practice potentially affected all residents. The facility census was 89 residents. 1. Review of the new Employee hire list showed the DM was hired on 9/7/23. During an interview on 11/18/24 at 12:49 P.M., the DM said he/she has worked as as DM since September 2023 and the facility has not assisted him/her in obtaining the requirements to be a CDM. During an interview on 11/20/24 at 3:49 P.M., the Administrator said: -He/She knew that the DM had worked more than a year. -He/She has spoken with the DM about obtaining the requirements to be a CDM,…

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

Based on observation, record review and interview, the facility failed to follow the menu on the following three occasions: Lunch on 11/17/24, lunch on 11/19/24 and dinner on 11/19/24. This practice potentially affected all residents. The facility census was 89 residents. 1. Review of the Week at Glance menu dated 2024 showed the 11/17/24 lunch meal consisted of: -Fried chicken. -Mashed potatoes with gravy. -Mixed greens. -Homemade Peach Crisp. -Dinner roll. Observation during the lunch service 11/17/24 from 11:45 A.M. through 12:35 P.M., showed the Homemade Peach Crisp was not served. During an interview on 11/178/24 at 11:53 A.M., Dietary [NAME] (DC) A said he/she ran out of time to make the Homemade Peach Crisp. 2. Review of the Week at Glance menu dated 2024 showed the 11/19/24 lunch meal consisted of: -Sweet and Sour Chicken. -Steamed Rice. -Oriental Vegetables. -Mandarin Orange Gelatin. Observation during the lunch service on 11/19/24 from 11:45 through 12:20 P.M., showed the residents received a rye swirl bread sandwich with fries. The residents did not get sweet and sour…

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 have an certified Infection Preventionist (IP) employed at the facility. The facility census was 89 residents. Review of the facility's undated policy, Required Primary Professional Training for Infection Preventionists, showed: -This policy was to define the primary professional training requirements for Infection Preventionists to ensure they possessed the knowledge and skills necessary to manage and prevent infections in healthcare environments. -The Infection Preventionist must complete training programs offered through CDC TRAIN (a comprehensive platform that provides access to online training materials and resources from the Centers for Disease Control and Prevention). -All completed training and certifications through CDC TRAIN must be documented and maintained in the employee's personnel record. 1. During an interview on 11/21/24 at 12:20 P.M. the Administrator said: -They have not had an IP employed at the facility since August this year. -He/She had started the course but had not finished it. During an interview…

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 carry out pest control measures to limit the presence of roaches in the kitchen, the dining room, and in resident rooms 214 and Resident #25's room. This practice affected all areas of the kitchen and the part of the dining room next to the kitchen. The facility census was 89 residents. 1. Observations on 11/17/24 from 8:58 A.M. through 12:47 P.M., showed: -Dead roaches in the drawer under the table with the microwave. -Roaches crawling on the wall behind reach-in refrigerator -Roaches inside of the electrical outlet behind ice machine. -Numerous roaches under the dishwasher, where there was a buildup of grime and food debris. During an interview on 11/17/24 at 9:24 A.M., the Dietary Manager (DM) said he/she was responsible for cleaning the food crumbs on the handrail and he/she noticed the roaches at the end of the hand rail. During an interview on 11/17/24 9:28 A.M., the DM said they could only scrub so much of the grime and food crumbs…

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 provide the required annual 12 hours of in-service training for Certified Nursing Assistants (CNA), and maintain records which indicate the subject of, and attendance at, all in-service sessions. The facility census was 89 residents. Review of the facility's CNA Continuing Education policy dated 5/25/23 showed: -All CNA's must complete a minimum of 12 hours of continuing education annually, in accordance with state and federal regulations. -Education may be provided through: --On-site training sessions. --Online learning platforms approved by the facility. --Workshops and seminars. -Supervisors will track compliance and maintain records in personnel files. -Failure to meet continuing education requirements may result in: --Written warnings. --Suspension of shifts until compliance is achieved. --Termination for repeated non-compliance. -The Director of Nursing (DON) will create an annual training schedule and ensure relevant topics are covered. -CNA's will be informed of mandatory training sessions via email, bulletin board…

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

Based on interview and record review, the facility failed to ensure the required bond amount was sufficient for the amount of the average monthly balance for the 12-month period from 11/23 through 10/24. This practice potentially affected 56 residents who allowed the facility to manage their resident trust accounts. The facility census was 89 residents. 1. Review of the Resident Funds Bond Worksheet showed: -The average monthly balance for 12 months of reconciled bank statements was $123,720.44. -The directions on the Resident Fund Bond Worksheet stated that amount should be rounded to the nearest thousand up or down. When rounded up, that amount was $124,000.00 -The directions on the Resident Funds Bond Works sheet then stated to multiply that amount by 1.5, after multiplied, that amount was $186,000.00. Review of the approved bond (an insurance agreement pledging that one entity will become legally liable for financial loss caused to another by the act or default of a third person), showed the bond amount was only $150,000.00 which was less than the required amount of $186,000.00.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain the handrails in the dining room free from a buildup of food crumbs; failed to maintain the restroom ceiling vents free of a dust buildup in the following resident rooms: 202, 203, 204, 205, 206, 209, 211, 223, 104, 103, 107, 108, 109, 111, and 112; failed to maintain the large orange fan at the north end of the first floor free from a buildup of dust; failed to maintain resident use fan in the following rooms free from a buildup of dust: resident rooms 201, 209, 104, and 111. This practice potentially affected at least 55 residents who resided in those rooms or used those areas. The facility census was 89 residents. 1. Observation on 11/17/24 at 9:24 A.M., showed: -A buildup of food crumbs in the handrails which were on the north wall of the dining room. -Roaches crawled next to where the end of the handrail joined the wall in the dining room. During an interview on 11/1/7/24 at 9:24 A.M., the Dietary Manager (DM) said he/she was responsible…

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 medications were not left at bedside for two sampled residents (Residents #23 and #50) and one supplemental resident (Residents #27) out of 18 sampled residents. The facility census was 89 residents. The facility did not have a policy regarding leaving medications at bedside or self medicating. 1. Review of Resident #23's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Depression (a common mental health condition that involves a long-lasting low mood or loss of interest in activities). -Psychosis (a mental disorder characterized by a disconnection from reality). -Vascular Dementia (brain damage caused by multiple strokes (damage to the brain from an interruption of its blood supply). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning) dated 9/20/24 showed: -He/She was admitted for Non Traumatic…

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 have a process in place to ensure Cardiopulmonary Resuscitation (CPR-a lifesaving technique useful in many emergencies, in which someone's breathing or heartbeat has stopped) certifications were on file for all staff with current CPR certification and certified staff were available on all shifts. This had the potential to affect 80 residents who were a full code status (would require CPR). The facility census was 89 residents. Review of the facility policy titled Policy for Medical Emergency Response dated 2023 showed: -At least one staff member must obtain CPR certification each shift, which may be a non-nursing staff member. -The facility will maintain a record of any staff members who are trained and capable of providing CPR and will be able to demonstrate current competency. Review of the facility policy titled CPR policy dated 2023 showed: -The Administrator and DON will review staffing to ensure a CPR certified nurse is on duty for each shift.…

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 acceptable nutritional status by not following physician instructions for weighing residents resulting in an unplanned weight loss for one sampled resident (Resident #56) out of 18 sampled residents. The facility census was 89 residents. Review of the facility's policy titled, Weight Management - Unplanned Weight Change dated 2023 showed: -The Director of Nursing (DON)/Assistant DON (ADON) would be responsible for establishing monthly/weekly weight schedule. -The appointed nursing staff were responsible for obtaining weight for each resident according to the schedule. -The staff who were responsible for weighing the residents would compare the current weight and the previous weight and re-weigh the resident if there was a five or more pound change. -Residents who exhibit weight gain or loss more than 5% in 30-day period; 7.5% in 90-day period or 10% in 180-day period shall be: --Assessed by a licensed nurse for causative factors,…

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 respiratory equipment such as oxygen tubing, Continuous Positive Airway Pressure (CPAP - a method of noninvasive ventilation assisted by a flow of air delivered at a constant pressure throughout the respiratory cycle), and a nebulizer (a device that was used to administer medication in the form of a mist inhaled into the lungs) were cleaned and stored in a sanitary condition for three sampled residents, (Resident #22, #34, and #62) out of 18 sampled residents. The facility census was 89 residents. Review of the facility's policy, Respiratory Therapy Policy, dated 2022 showed: -The equipment should have the individual's name and have been cleaned by the staff (the policy did not stated how often) and as needed. -Tubing, cannula, and bottle should have been stored properly in an infection controlled manner. Review of the facility's policy, Policy for Respiratory Care Equipment, dated 2022 showed: -To maintain the proper infection…

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 staffing was posted correctly at the beginning of each shift including the total number and actual hours of nursing staff worked per shift which could have the potential to affect all visitors and residents in the facility. The facility census was 89 residents. A policy regarding posting staffing was requested but not received at the time of exit. Observation on 11/17/24 at 8:30 A.M., showed: -No posted staffing noted at the front entrance reception or the first-floor nurse's station. During an interview on 11/17/24 at 9:40 A.M., Certified Medication Technician (CMT) C said: -He/She was not sure where the staffing sheets were located, he/she said probably at the nurse's station. -The first floor had one Registered Nurse (RN), one CMT, and one Certified Nursing Assistant (CNA) for this shift. -The residents on the first floor were mostly self-care residents. -The second floor had one nurse, one CMT, and two CNAs. Observation on 11/17/24 at 12:38 P.M., of the second-floor staffing sheet showed: -The…

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

Based on observation, interview, and record review, the facility failed to ensure the only sink in the Medication Room on the first floor was clean, failed to ensure staff was checking the refrigerator temperature which held the residents prescribed medications, failed to ensure there were no expired medications in the medication refrigerator, and failed to ensure resident's prescribed medications were stored in a dry environment. The facility census was 89 residents. Review of the facility's policy,Storing Medications/Medication Carts, dated 2019 showed: -Drugs were to have been stored at proper temperatures. -Drugs requiring storage at room temperatures were to have been stored at a temperature of not less than 36 degree Fahrenheit (F) or more than 46 degrees F. -A thermometer was to have been kept in the refrigerator containing medications to help assure proper temperatures. -Drugs were not to have been kept on hand after the expiration date which appeared on the label. -Outdated, contaminated, or deteriorated drug, and those in containers which were cracked, soiled or without…

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

Based on observation and interview, the facility failed to ensure that Dietary Aide (DA) A's hair completely within a hair restraint; failed to ensure a bottle of jelly was refrigerated according to the label; failed to remove the grime from under the dishwasher; failed to clean the fan vent covers in the walk-in refrigerator; failed to remove food buildup from the bread toaster knobs; and failed to ensure the fan closest to the steam table was free from dust on the blades of the fan. This practice potentially affected all residents who ate food from the kitchen. The facility census was 89 residents. 1. Observations on 11/17/24 from 8:50 A.M. through 12:50 P.M., showed: -DA A worked in the the kitchen with his/her hair not completely restrained from 8:50 A.M. through 10:58 A.M. -One bottle of jelly not in the refrigerator label which stated Refrigerate After Opening. -A buildup of grime on the pipes under the dishwasher. -A buildup of food grime and crumbs on the bread toaster knobs. -A buildup of dust on the fan vent covers of the walk-in refrigerator. During an interview on…

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 follow their policy for tuberculosis (TB-a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) screening annually for five sampled residents (Residents #22, #23, #58, #79, and #56) out of five residents sampled for TB; failed to ensure proper infection control practices were followed in the monitoring of blood glucose levels for five sampled residents (Residents #36, #140, #142, #33, and #143), by not sanitizing a glucometer (machine that measures the amount of blood sugar in a resident's blood) between uses; failed to maintain records of complete screening of new employees for TB for 10 sampled employees (Employee A, B, C, D, E, F, G, H, J, and K) out of 92 new employees; failed to initiate Enhance Barrier Precautions (EBP) in the facility, including one sampled resident (Resident #7), failed to educate staff on EBP, and failed 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 ensure an influenza (flu) vaccine (an annual vaccine to protect against the influenza virus) was offered to three sampled residents (Residents #22, #23, and #79) and failed to ensure pneumococcal (pneumonia) vaccine (a vaccine to protect against pneumococcal disease caused by the bacteria Streptococcus pneumoniae) was offered, administered or documented five years after a previous pneumonia vaccine for two sampled resident (Resident #23, and #56) out of five residents sampled for immunizations. The facility census was 89 residents. Review of the facility's policy titled Influenza and Pneumococcal Immunizations dated 2023 showed: -All newly admitted residents will be offered to receive the immunizations of influenza and pneumococcal in the facility. -Education was provided at the admitted or agreement time. -Flu vaccines were offered yearly. -Residents would be offered flu immunizations from October through March 31 annually unless medically…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the 2024-2025 COVID-19 (a new disease caused by a novel (new) coronavirus) vaccine was offered, administered, or documented for two sampled residents (Resident #23 and #79) out of five residents sampled for immunizations. There were 18 residents in the survey sample. The facility census was 89 residents. Review of the Centers for Disease Control and Prevention (CDC) website dated 10/3/24 showed everyone ages 6 months and older should get a 2024-2025 COVID-19 vaccine. A COVID-19 vaccine policy was requested but not provided by the facility. 1. Review of Resident #23's entry tracking forms showed the resident was originally admitted to the facility on [DATE]. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff) dated 9/20/24 showed the staff assessed the resident as severely cognitively impaired. Review of the resident's immunization record showed: -The resident received the two…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and interview, the facility failed to ensure the facility's call system was audible at the attendant's area for the residents on the 2nd floor. This practice potentially affected 46 residents who resided on the 2nd floor. The facility census was 89 residents. 1. Observations on 11/18/24 showed: -At 10:04 A.M., there was no audibility (the quality or state of being able to be heard) at the nurse's station, when the call light in resident room [ROOM NUMBER] was activated. -At 10:11 A.M., there was no audibility at the nurse's station when the call light in resident room [ROOM NUMBER] was activated. -At 10:15 A.M., there was no audibility at the nurse's station when the call light in the shower room was activated. -At 10:31 A.M., there was no audibility at the nurse's station when the call light in the whirlpool room was activated. -At 10:48 A.M., there was no audibility at the nurse's station when the call light in resident room [ROOM NUMBER] was activated. -At 10:51 A.M., there was no…

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

Based on observation and interview, the facility failed to ensure there was not a heavy buildup of dust under the vending machines in the second floor dining room and failed to ensure the threshold (a horizontal strip of material that covers the gap between the floor and a door frame) of the door between the carport and the basement entrance was securely affixed to the floor. This practice potentially affected at least 25 residents who used the carport as a smoking area and an unknown number of facility staff who entered the facility through that door. The facility census was 89 residents. 1. Observation on 11/18/24 at 10:39 A.M., showed a heavy buildup of dust under the vending machines in the 2nd floor dining room. During an interview on 11/18/24 at 10:40 A.M., the Maintenance Director said: -It was difficult for staff to get under the vending machines because the vending machines are heavy and difficult to move. -He/She would have to call the vending machine company to move the machines so his/her staff can clean under the machines. 2. Observations on 11/17/24 at 12:35 P.M.,…

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 each resident was treated with dignity and respect by not maintaining and enhancing self-esteem, self-worth, and not incorporating individual preferences and choices during assisted feeding for one sampled resident (Resident #56) out of 18 sampled residents. The facility census was 89 residents. Review of the facility's Feeding - Helpless Patient guidelines, undated, showed: -The purpose was to ensure adequate nutrition for those residents who were unable to feed themselves. -Tell the resident they are going to be fed. -If the resident was blind, tell him/her what was being done to feed him/her. -Feed slowly to prevent choking. -Use a straw to give liquids. -When finished wipe the resident's face with a napkin or washcloth. Review of the facility's Feeding Patient-Assisting with Meals guidelines, undated, showed: -Whenever possible feed two to four residents at a time to allow more time for chewing while feeding the other resident. Review of the Resident Rights-Dignity and Privacy Policy, dated 2023,…

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 conduct a Criminal Background Check (CBC) and Employee Disqualification List (EDL) check for three sampled employees (Employees D, J and K) and to maintain records of the Social Security number, date of birth , date of employment, experience and education, references and the result of background checks required by section 660.317 of Revised MO Statutes for two employees (Employees J and K) out of 10 employee files requested. The facility census was 89 residents. Review of the Facility's Policy entitled Nursing Home Employee/Personal Records Policy dated 2022 showed: -Policy Statement: The facility is committed to maintaining accurate and confidential employee records, ensuring compliance with all applicable laws and regulations while providing employees with appropriate access to their personal employment information. -Scope: This policy applies to all current, former, and prospective employees of the Facility Record Types: Employment Application: Including contact information, employment history, education, references,…

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 plan, coordinate, and provide a safe and appropriate discharge when the facility initiated an immediate discharge for one sampled resident (Resident #76) out of 36 sampled residents. The resident's discharge notice stated the transfer location was Facility B, however, the resident was transported to the hospital via Emergency Medical Services. Facility B was unaware the resident was to be discharged to them. The facility census was 86 residents. Review of the facility's Discharge and Transfer Resident policy, dated 12/21/24, showed: -The purpose of the policy was to ensure the appropriate procedure for transferring and discharging a resident. -All residents who were discharged out of the facility under any circumstance was given an order from the attending physician. -Provide written instruction with verbal explanation regarding care, treatment, use of medications or devices to the resident upon discharge. -Order to discharge included the date and time…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the resident and/or the resident's representative(s) of a transfer to a hospital, including the reason for the transfer in writing and failed to provide the Ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) a copy of the notification for two sampled residents (Residents #14 and #30) when sent to the hospital out of 18 sampled residents. The facility census was 89 residents. Review of the facility's Bed-Hold Policy and readmission dated 2021 showed: -At the time of transfer of a resident for hospitalization the facility will provide to the resident and a family member or legal representative written notice. -Notify the family or legal representative and physician about the discharge and reason. -Logging on the discharge log (hospital transfer) by the Social Services Designee (SSD) or charge nurse to fax monthly to the Ombudsman office. -NOTE: There was not a separate policy…

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 allow one sampled resident (Resident #76) to return to the facility after an emergency discharge notice was given to the resident, during the appeal process and once the appeal showed the resident was allowed to return to the facility out of 8 sampled residents. The facility census was 89 residents. Review of the facility's Discharge and Transfer Resident policy, dated 12/21/24, showed the purpose of the policy was to ensure the appropriate procedure for transferring and discharging a resident. In case of involuntary discharge: -The Safety Committee establishes the interventions and implements immediately. -The physician shall be consulted for further interventions. -The assessment and order must be documented in the medical record. -Involuntary discharge can be immediately in an emergency if the safety of individuals at the facility was endangered due to clinical or behavioral status of the resident; The safety of individuals in the facility is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to accurately complete the Resident Assessment Instrument/Minimum Data Set (RAI/MDS-a document which helped nursing home staff gather information on a resident's strengths and needs), which was used to address a resident's individual care plan (a document created for a person that received healthcare, personal care, or other forms of support) when it failed to accurately assess and record the use of bed rails (a rail or board attached to the bed that can reduce the risk of residents rolling, sliding, slipping or falling out of bed and sustaining a serious injury), for one sampled resident (Resident #56) out of 18 sampled residents. The facility census was 89 residents. Review of the facility's RAI Process Protocol Policy, dated 2022, showed: -The purpose of the policy was to ensure accuracy and timeliness of all MDS assessments. -To develop a comprehensive care plan that reflected the resident's level of care and to meet their needs. -In 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 review and revise a resident's person-centered care plan (a document created for a person that received healthcare, personal care, or other forms of support) when it failed to ensure resident safety by not addressing the use of bed rails (a rail or board attached to the bed that can reduce the risk of residents rolling, sliding, slipping or falling out of bed and sustaining a serious injury), for one sampled resident (Resident #56) and failed to ensure the resident's care plan was accurate by dating it eight days after the resident discharged from the facility for one sampled resident (Resident #90) out of 18 sampled residents. The facility census was 89 residents. Review of the facility's Policy for Care Plan, dated 2022, showed: -The purpose of the policy was to: --To effectively communicate a resident's comprehensive plan of care to all staff. --To develop a new care plan and revise an existing care plan that needed to accommodate resident's needs…

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 staff were smoking in designated smoking areas; and failed to ensure two sampled residents (Resident #50 and #55) were smoking in designated smoking area and not smoking in resident rooms, out of 18 sampled residents. The facility census was 89 residents. Review of the facility's policy, Resident Smoking Policy, dated 5/03/12 showed: -Each resident who smoked would have been reassessed quarterly for the safe smoking capacity. -If a resident began to exhibit unsafe smoking practices, that resident would have been immediately reassessed. -Residents were allowed to smoke at designated times (which were posted and announced). -They were allowed to smoke in designated smoking areas. -The smoking areas were the Day Room on each Resident Care floor and outside of the facility. -Resident smoking material would have been locked up and would have been passed out by the staff member who was assigned to supervise the resident during smoking…

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 ongoing communication and collaboration with the dialysis (the process of removing blood from an artery (as of a kidney patient), purifying it by dialysis, adding vital substances, and returning it to a vein) facility regarding dialysis care and services for one sampled resident (Resident #7) out of 18 sampled residents. The facility identified two residents as receiving dialysis. The facility census was 89 residents. Review of the facility's policy titled Policy on Dialysis and Care for the Shunt (a surgically created connection between an artery and a vein that provides access to the bloodstream for dialysis) dated 2023 showed instructions to: -Send a communication record for dialysis treatment each day the resident attended dialysis and complete the section of form titled Completed by [NAME] Manor Nursing Home. -Provide information and training on what information is obtained from the dialysis center, how the information is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident safety by not following their Restraint Policy and providing bed rails (a rail or board attached to the bed that can reduce the risk of residents rolling, sliding, slipping, or falling out of bed) to one resident (Resident #56) out of 18 sampled residents. The facility census was 89 residents. Review of the facility's Side (Bed) Rail Policy, dated 2024, showed: -Residents with compromised mobility were reassessed upon admission for the use of bed rails. -Residents who used bed rails were screened or assessed monthly according to the monthly assessment schedule. -The care plan reflected the use of bed rails. -The care plan team discussed the use of bed rails during care plan meetings. -The physician was notified of the assessment and recommendations. -Residents who used bed rails were alerted to all nursing staff or frequent checks and observations. -The risks involved with the use of bed rails was discussed with the…

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

Based on observation, interview and record review, the facility failed to ensure that foods stored in the resident use refrigerator was labeled with a resident's name and the date the food was brought in to clearly identify it as a food brought in by visitors and guests. This practice potentially affected at least three residents whose food was stored in the refrigerator. The facility census was 89 residents. Review of the facility's policy entitled Regarding Use and Storage of Foods Brought to Residents by Family and Other Visitors dated 2109, showed: -The facility is responsible for storing food brought in by family or visitors in a way that is either separate or easily distinguishable from facility food. -Clear identify what food has been brought in by visitors for residents and guests when served. 1. Observation on 11/20/24 at 11:38 A.M. showed the refrigerator at the 2nd floor nurse's station had: -One package of ham that was expired on 11/6/24. -One container of milk that was opened and expired on 10/29/24. -Two packages of food without a name of a resident or labeled with 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 and interview, the facility failed to maintain the outdoor dumpster with the lids closed. The facility census was 89 residents. 1. Observation on 11/17/24 at 9:08 A.M. 9:58 A.M. ,and 10:15 A.M., showed the lid of the outdoor dumpster, remained open. 2 Observations on 11/18/24 at 9:49 A.M., 1:27 P.M., 2:06 P.M., and 2:47 P.M., showed the lid of the outdoor dumpster, remained open. 3. Observations on 11/18/24 at 11:20 A.M., and 12:33 P.M., showed the lid of the outdoor dumpster, remained open. During an interview on 11/18/24 at 12:35 P.M., Dietary [NAME] (DC) A said he/she expected facility staff to close the lids after they dump trash. During an interview on 11/18/24 at 12:50 P.M., the Dietary Manager (DM) said he/she expected facility staff to close the lids of the outdoor dumpster.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the resident's care plan was accurate by dating it eight days after the resident discharged from the facility for one sampled resident (Resident #90) out of 18 sampled residents. The facility census was 89 residents. Review of the facility's policy titled Care Plan dated 2019 showed: -The comprehensive care plan was required to be completed within 21 days of admission. -The Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) coordinator follows the Resident Assessment Instrument (RAI - helps the facility staff to gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan) manual to develop the care plan and coordinates the RAI process. -The care plan schedule follows the RAI requirements and can be reviewed and revised anytime to ensure it reflected the resident's current conditions. 1. Review of Resident #90's entry tracking…

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 report two allegations of resident to resident abuse for two sampled residents (Resident #1 and Resident #6) when on 7/3/24 Resident #2 hit Resident #6 in the mouth causing a small cut on the resident's lower lip and on 7/22/24 Resident #2 hit Resident #6 causing laceration to both sides of his/her cheeks out of 10 sampled residents. The facility census was 85 residents. Record review of the facility's policy for Abuse and Neglect, revised in 2022 showed: -Each resident had the right to be free from abuse. -Abuse was defined as the willful infliction of injury resulting in physical harm, pain or mental anguish, with physical abuse resulting in bodily injury, physical pain, or impairment. Physical abuse included hitting, slapping, punching and kicking. -All incidents of abuse were to have been reported immediately to the charge nurse on duty who was to in turn, report to the Director of Nursing (DON) and/or the Administrator. -All staff were to have…

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 investigate an allegation of resident to resident abuse for one sampled resident (Resident #6 ) when on 7/3/24 Resident #2 entered Resident #6's room and hit him/her in the mouth and cut his/her lip out of 10 sampled residents. The census was 85 residents. Record review of the facility's policy for Abuse and Neglect, revised in 2022 showed: -All allegations of abuse were to have been investigated immediately by facility administrative staff. -The facility was to have investigated who was involved, any injuries sustained, and if the residents needed hospital care. 1. Review of Resident #2's Preadmission Screening and Resident Review (PASRR, DA-124C, a required form to be submitted for any client who requests admission to a Medicaid certified bed regardless of the client's payment source; this includes dually certified beds both Medicare and Medicaid), dated 10/25/23, showed he/she had the following diagnoses: -Anxiety Disorder (a psychiatric disorder…

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 appropriate treatment and services to deescalate one sampled resident (Resident #2) out of 10 sampled residents, who was displaying emotional and behavioral adjustment difficulty. The facility census was 85 residents. Record review of the facility's policy for Behavior Management, revised in 2022 showed: -The purpose of the policy was to maintain and promote a healthy environment that provided comfort to the residents. -The policy was also to help the facility staff detect early on, any changes in psychosocial status and appropriate interventions. -The facility staff was to monitor residents with fluctuated behaviors or new behavior symptoms for any underlying medical conditions. -The facility staff was to observe the residents daily and document on the behavioral flow sheet any intensity of behaviors. -The observations can be increased to every shift as needed. -The Director of Nursing (DON) was to review and determine the time frame for…

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 provide proper notification for an immediate discharge for one sampled resident (Resident #1) out of ten sampled residents. The facility census was 86 residents. Review of the facility's Discharge and Transfer Resident policy, undated, showed: -The purpose of the policy was for transferring and discharging residents. -All residents who discharged out of the facility under any circumstances will have an order from his/her attending physician. -Procedure: --Assess resident condition and determine the needs for transferring or discharging using nursing or professional judgement. --Provide a written instruction with verbal explanation regarding care, treatment, use of medications or devices to the resident or his/her responsible party. -Discharge based on disruptive, dangerous, violent behavior that affect the safe living environment. --Examples included: harm to others, suicidal attempts, physical or sexual violent/abusive behavior that was determined by the Quality Assurance Team/Safety Committee that the behavior was not…

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 plan for discharge for one sampled resident (Resident #1) out of ten sampled residents. The facility census was 86 residents. Review of the facility's Discharge and Transfer Resident policy, undated, showed: -The purpose of the policy was for transferring and discharging residents. -All residents who discharged out of the facility under any circumstances will have an order from his/her attending physician. -Procedure: --Assess resident condition and determine the needs for transferring or discharging using nursing or professional judgement. --Provide a written instruction with verbal explanation regarding care, treatment, use of medications or devices to the resident or his/her responsible party. -Discharge based on disruptive, dangerous, violent behavior that affect the safe living environment. --Examples included: harm to others, suicidal attempts, physical or sexual violent/abusive behavior that was determined by the Quality Assurance Team/Safety Committee that the behavior was not controllable or able to be redirected.…

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 staffing was posted correctly at the beginning of each shift including the census and the total number and actual hours worked per shift which could have the potential to affect all residents in the facility. The facility census was 86 residents. Record review of the facility's policy titled Policy for Staffing dated from 2020 showed the staffing board must be displayed for three shifts in public areas (no name, number of Registered Nurse (RN), Licensed Practical Nurse (LPNs), and Certified Nursing Assistants (CNAs). 1. Observation on 4/14/23 at 9:25 A.M. of the daily staffing sheet on 200 hall showed: -The staffing clipboard was flipped upside down behind the nurse's station. -No census included on the sheet. -The total number and actual hours worked per shift for the nurses, Certified Medication Technician (CMTs), and CNAs was not included on the sheet. Observation on 4/17/23 at 10:01 A.M. of the staffing clipboard on 200 hall showed: -No new staffing sheets posted on the clipboard. -No 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, the facility failed to ensure a director of food and nutrition services who met the qualifications of a Dietary Manager (DM), was employed since the previous DM left employment at the facility 63 days prior to the start of the survey. This practice potentially affected all residents. The facility census was 86 residents. 1. Observation on 4/10/23 at 8:48 A.M., through 1:22 P.M., showed the absence of a DM from the kitchen. During an interview on 4/10/23 at 9:11 A.M., Dietary [NAME] (DC) A said the previous DM resigned about six to seven months ago. Observations on 4/10/23 from 8:48 A.M. through 1:22 P.M., showed: - A roll of ground meat on a tray without a date that it was taken from the freezer without a date. - Three cutting boards with numerous indentations. - DC A placed bread sticks on pan without gloving his/her hands. - DC A said there were not thermometer probe wipes in the kitchen. - DC A cooked chicken noodle soup instead of the mushroom hamburger steak which was on the menu. During an interview on 4/14/23 at 11:46 A.M.,…

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 follow the menu on 4/10/23 by not preparing the meal that was supposed to be prepared on that date according to the Week at a Glance Menu. This practice potentially affected all residents. The facility census was 86 residents. 1. Record review of the Week at a Glance Menu for Week 1 Day 2 showed the following lunch meal: - Mushroom hamburger steak. - Buttered egg noodles. - [NAME] peas. - Cottage cheese with fruit. - Breadstick and beverage. Observation on 4/10/23, showed: - At 10:43 A.M., Dietary [NAME] (DC) A cooked the noodles and placed the noodles in a colander. - At 11:06 A.M., DC A placed frozen packets of chicken soup into a pot for heating. - At 11:10 A.M., DC A placed breadsticks on pan to be placed into the oven for heating. - At 11:23 A.M., DC A placed the breadsticks into a pan for placing the breadsticks on steam table. During an interview on 4/10/23 at 12:41 P.M., DC A said the reason why he/she substituted the mushroom hamburger steak for chicken noodle soup, was because he/she guessed 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 and interview, the facility failed to place the date on food that was taken from the freezer and placed into the refrigerator for defrosting; to ensure that all employees wore appropriate hair restraints; to maintain two fans in the kitchen are free from a heavy buildup of dust and one of them from blowing air towards the steam table; to maintain the vent above the steam table free from a buildup of dust; to maintain the shelf above the six burner stove free from a buildup of dust; to maintain the nozzles of the dishwasher spray wands free from debris; to maintain three cutting boards from conditions which made them not easily cleanable; to ensure there were alcohol wipes available to wipe thermometers after use; to ensure Dietary Aide (DA) B washed his/her hands between going from soiled dishes to clean dishes; and to ensure utensils or gloved hands were used to pick up breadsticks. This practice potentially affected all residents who were served food out the kitchen. The facility census was 86 residents. 1. Observations on 4/10/13 from 8:48 A.M. through 1:23…

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 maintain clinical records in accordance with accepted professional standards and practices that are complete, accurately documented, and readily accessible, by not providing immunization records for one sampled resident (Resident #30) out of 21 sampled residents and requested policies. The facility census was 86 residents. 1. Requested, verbally to Administrator, on 4/10/23 at 10:09 A.M. the facility's Resident Vaccination Policy. -Requested, in writing to the Administrator, on 4/14/23 at 3:25 P.M. a copy of the facility's Resident Vaccination Policy. -This policy was not received at time of exit. 2. Record review of Resident #30's face sheet showed he/she was admitted with the following diagnoses: -Major Depressive Disorder. -Heart Failure. -Brief Psychotic Disorder. A request was made for Resident #30's vaccination record in writing to the Administrator on 4/14/23 at 3:00 P.M. During an interview on 4/17/23 at 12:55 P.M., the Administrator said the information requested was difficult to gather because it was not…

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 submit the Payroll Based Journal data (PBJ- a report that provides staffing dataset information submitted by nursing homes on a quarterly basis) for the last four quarters which had the potential to affect all residents. The facility census was 86 residents. 1. Record review of the facility PBJ Quarter Two (2022) from 1/1/22-3/31/22 showed no data submitted for the quarter. Record review of the facility PBJ Quarter Three (2022) from 4/1/2022-6/30/22 showed no data submitted for the quarter. Record review of the facilty PBJ Quarter Four (2022) from 7/1/22-9/30/22 showed no data submitted for the quarter. Record review of the facilty PBJ Quarter One (2023) from 10/1/2022-12/31/22 showed no data submitted for the quarter. During an interview on 4/14/23 at 10:00 A.M., the Administrator said the Director of Nursing (DON) took over staffing six weeks ago. During an interview on 4/17/23 at 10:03 A.M., Licensed Practical Nurse (LPN) B said he/she did not know who submitted the PBJ data. During an interview on 4/17/23 at 11:33 A.M.…

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 provide records of all in-services completed within the last 12 months including abuse and neglect training. This had the potential to affect all residents. The facility census was 86 residents. 1. The last 12 months of in-services was requested at the following times: -4/14/23 at 8:54 A.M. -4/17/23 at 9:12 A.M. During an interview on 4/17/23 at 9:47 A.M., Licensed Practical Nurse (LPN) B said: -He/she was unsure if education was provided after a resident-to-resident altercation occurred on 3/28/23. -He/she had received abuse and neglect training sometime last year. -He/she was unsure of other in-service training he/she had in the last year. During an interview on 4/17/23 at 11:25 A.M., Certified Medication Technician (CMT) A said he/she thought there had been education on abuse and neglect provided after the resident-to-resident altercation occurred on 3/28/23. During an interview on 4/17/23 at 11:52 A.M., Registered Nurse (RN) A said: -Education/In-services to staff should be provided after a resident-to-resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess the residents' ability to self-administer medications, monitor for safe administration, monitor storage of self-administered medication, and obtain a physician's order for self-administration of medications for four sampled residents (Resident #80, #77, #59, and #36) out of 21 sampled residents. The facility census was 86 residents. Record review of the facility's policy titled Policy for Non-Prescribing Medications and Self-Administration of Medication, dated 2017, showed: -Staff were to ensure residents that self-administer their own medications had the medications stored in a designated, locked, area in their room. -All bedside medications were to be approved and ordered by the physician. -Nursing staff were responsible for monitoring and ensuring the resident appropriately administered their own medication. -Nursing staff were responsible for ensuring the safety of bedside medications by checking storage of medications daily.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to clean the fans in resident rooms 209, 122, 111, 105, 104, and the resident use area of the therapy office; to maintain the ceiling vents in the 2nd floor whirlpool room, resident rooms [ROOM NUMBER]; and to maintain the commode seats in an easily cleanable condition in resident rooms [ROOM NUMBER]. This practice potentially affected at least 25 residents who resided in or used those areas. The facility census was 86 residents. 1. Observation with the Maintenance Director (MD) on 4/11/23, showed: - At 10:06 A.M., a heavy buildup of dust was present on the fan blades in resident room [ROOM NUMBER]. - At 11:40 A.M., a heavy buildup of dust was present on the fan blades resident room [ROOM NUMBER]. - At 12:13 P.M., a heavy buildup of dust was present on the fan blades in the Director of Nursing's (DON's) office. - At 12:25 P.M., a heavy buildup of dust was present on the fan blades in resident room [ROOM NUMBER]. - At 12:38 P.M., a heavy buildup of dust was…

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 complete a thorough investigation of two resident-to-resident physical altercations on 3/28/23 between two supplemental residents (Resident #44 and Resident #82); to complete a timely investigation for a resident to resident altercation between two supplemental residents (Resident #58 and Resident #34), and to document monitoring of the residents after the incident to prevent further altercations out of 21 sampled residents and 14 supplemental residents. The facility census was 86 residents. Record review of the facility's policy titled Policy Regarding Abuse and Neglect of Facility Residents dated from 2020 showed: -All suspected incidents must be investigated immediately. -Report to the charge nurse on duty, which in turn will report to the Administrator or Director of Nursing (DON), and physician. -The Administrator/DON will initiate an investigation immediately upon incident reported. Record review of the facility's policy titled…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the bed hold was signed and a copy of the bed hold was retained and provided for two sampled residents (Resident #78 and Resident #16) and one closed record sampled residenet (Resident #86), prior to or upon hospitalization out of 21 sampled residents. The facility census was 86 residents. Record review of the facility ' s policy titled Bed Hold Policy and Readmission dated from 2021 showed: -At the time of transfer of a resident for hospitalization or therapeutic leave, [NAME] Manor will provide to the resident and a family member or legal representative written notice which specifies the duration of the bed-hold policy. -Staff follows the policy to provide this notice when the resident is discharged . 1. Record review of Resident #78's Face Sheet showed he/she was admitted on [DATE], with diagnoses including high blood pressure, schizophrenia (a severe psychiatric disorder with symptoms of emotional instability, detachment from reality, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the care plan was comprehensive, available to the care staff, and addressed five sampled residents' (Resident #19, #72, #30, #59, and #75) health status out of 21 sampled residents. The facility census was 86 residents. 1. Record review of Resident #72's Face Sheet showed he/she was admitted on [DATE], with diagnoses including a left ankle fracture, elevated blood pressure, anxiety, alcohol abuse, depression, sleep apnea (a common disorder in which you have one or more pauses in breathing or shallow breaths while you sleep). Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 1/4/23 showed the resident: -Was alert, oriented and had no confusion. -Was independent with transfers, mobility needed supervision with dressing, bathing, eating, hygiene, toileting and used a wheelchair for mobility. -Had a fracture and was unsteady,…

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 results from orthopedic clinic were obtained for one sampled resident (Resident #39) who was seen for follow up for a right arm fracture and to document whether results from the service were provided to the physician; to ensure the administration of a resident's medication by leaving medications at the bedside and unattended by staff and/or residents for four residents (Resident #80, #77, #59, and #36), and to accurately assess a resident's ability to safely smoke for one sampled resident (Resident #80) out of 21 sampled residents. The facility census was 86 residents. 1. Record review of Resident #39's Face Sheet showed he/she was admitted on [DATE], with diagnoses including stroke, high blood pressure, heart disease, and high cholesterol. Record review of the resident's significant change Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 2/28/23 showed 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 properly store the oxygen nasal cannula/tubing (used to deliver oxygen through the resident's nose), nebulizer mask/mouthpiece (used for aerosol breathing treatments), and bi-level positive airway pressure face mask (bipap-a type of ventilator that helps with breathing) in a manner to prevent the spread of infection for two sampled residents (Resident #77 and #80) and one supplemental resident (Resident #2) out of 21 sampled residents. The facility census was 86 residents. Record review of the facility's policy, dated 10/5/21, titled Policy for Respiratory Care Equipment showed: -For nebulizers, staff were to place in a plastic bag or store in a dust free area. -For face masks and nasal cannulas, staff were to store in a plastic bag labeled with the date and resident's name. -Nasal cannulas were to be changed weekly and as needed when soiled or contaminated. 1. Record review of Resident #77's face sheet showed he/she was admitted 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 observation interview and record review, the facility failed to have enough facility staff available to deliver room trays in an expeditious matter; to maintain the salad at a temperature at or close to 41 ºF (degrees Fahrenheit) and to maintain the chicken noodle at a temperature at or close to 120 ºF at the time of service of the lunch meal test tray. This practice potentially affected at least 6 residents who received their meals closer to the end of the meal delivery service on the 2nd floor. The facility census was 86 residents. 1. Observations on 4/10/23 from 12:04 P.M. through 12:08 P.M., showed the temperatures of the following items in the kitchen, before delivery to the resident floors: -The salad was 50.3 ºF. -The green peas were 203.6 º. -The bread sticks were 158.1 ºF. -The chicken noodle soup was 152.3 ºF Observation on 4/10/23 at 12:25 P.M., showed Dietary [NAME] (DC) A placing plates of breadstick and chicken noodle soup in the cart that was to be delivered to the 2nd floor. Observation…

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 maintain facility records that were readily accessible to include staffing sheets; a record of all staff, including contracted staff, COVID-19 (a new disease caused by a novel (new) coronavirus) vaccinations, and to provide record of any performance reviews completed on Certified Nursing Assistants (CNAs) within the last 12 months. This had the potential to affect all residents. The facility census was 86 residents. 1. Staffing sheets were requested from the Administrator, in writing, on: -4/13/23 at 9:25 A.M. -4/14/23 at 8:54 A.M. -4/17/23 at 9:12 A.M. During an interview on 4/17/23 at 12:55 P.M. the Administrator said: -He/she and Corporate would gather a report that was generated from the time clock data and would send the file to him/her. -He/she would convert the data into a file format that is sent to the Payroll Based Journal (PBJ). -He/she had not reviewed the PBJ reports and did not know whether they showed if the reports had been sent or not. -He/she was not aware that the DON had not provided the monthly…

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 sufficient information that all facility pets were vaccinated. The facility census was 86 residents. Record review of the facility's policy, dated 2012, titled Policy for Pets showed: -All pets were to be up to date with required vaccinations. Record review of City of Kansas City, Missouri-Code of Ordinances, Chapter 14, dated 3/23/23, showed: -Section 14-20 required all residents within Kansas City to procure a license from the commissioner to keep a cat as a pet. -Section 14-24 required a certificate from a licensed veterinarian showing that each animal had been vaccinated against rabies in accordance with Compendium of Animal Rabies Prevention and Control issued annually by the National Association of State Public Health Veterinarians (NASPHV). 1. During an interview on 4/10/23 at 3:17 P.M., the Administrator said the facility had five cats in the facility that were all facility pets. Department of Health and Senior Services (DHSS) requested all five animal vaccination records: -Verbally 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.

Based on interview, and record review, the facility failed to develop and implement policies and procedures to ensure all staff were either vaccinated for COVID-19 (a disease caused by a virus names SARS-CoV-2), or had an approved exemption. This failure included the initial and ongoing monitoring for compliance of facility staff vaccination/exemption status. The facility census was 86 residents. Record review of the Center for Disease Control (CDC) Revised Guidance for Staff Vaccination Requirements dated 10/26/22 showed: -Facility staff vaccination rate under 100% constituted non-compliance. -Regardless of clinical responsibility or resident contact, the policies and procedures was required to be applied to facility employees, licensed practitioners, volunteers, and contracted employees. -The facility was to have a process for ensuring all staff were fully vaccinated against COVID-19 unless a religious or medical exemption had been approved. -Facilities were required to have a process for tracking and securely documenting COVID-19 vaccination status of all employees, including…

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 one supplemental resident (Resident #44) was free from abuse when Resident#82 pushed him/her against the wall of the smoking room with an ashtray pedestal and then pushed him/her into a scale in the hallway resulting in a bruise to his/her hip out of out of 21 sampled residents and 14 supplemental residents. The facility census was 86 residents. Record review of the facility's policy titled Policy Regarding Abuse and Neglect dated from 2020 showed: -Each resident has the right to be free from abuse. -The facility is responsible to prevent abuse. -Residents must not be subjected to abuse by anyone, including other residents. -The suspected victim must be protected immediately by being separated or removed from the suspect. 1. Record review of Resident #44's undated face sheet showed he/she admitted to the facility on [DATE] with the following diagnoses: -Alcohol Abuse (the habitual misuse of alcohol). -Depression, Unspecified (a 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report the findings of an investigation of a resident-to-resident physical altercation on 3/28/23 between two supplemental residents (Resident #44 and Resident #82) in which Resident #82 pinned Resident #44 against a wall in the smoking room; and to report an additional altercation between the same supplemental residents (Resident #44 and Resident #82) in which Resident #82 pushed Resident #44 into a scale on 3/28/23 out of 21 sampled residents and 14 supplemental residents. The facility census was 86 residents. Record review of the facility's policy titled Policy Regarding Abuse and Neglect of Facility Residents dated from 2020 showed: -The suspected incident will be investigated immediately. -Division of Health and Senior Services will be contacted if investigation is found valid. Record review of the facility's policy titled Policy for Investigation and Reporting of Abuse and Neglect dated from 2020 showed: -Any incidence of abuse, neglect, 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 interview and record review, the facility failed to incorporate information from the Pre-admission Screening and Resident Review (PASARR) into developing a comprehensive care plan for one sampled resident (Resident #75) out of 21 sampled residents who had a history of mental illness, suicide attempts and arson from his/her distant past. This practice of not developing a care plan based on the information from the PASARR caused facility staff and the Nurse Practitioner (NP) Psychiatrist to not be fully informed about the resident to formulate his/her care. The facility census was 86 residents. 1. Record review of Resident #75's undated face sheet showed he/she was admitted to the facility on [DATE] and had diagnoses which include: -Bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). -Post-traumatic stress disorder (a mental health condition that's triggered by a terrifying event--either experiencing it or witnessing it).…

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 care plans were updated to show the resident's current health status for one sampled resident (Resident #78) out of 21 sampled residents. The facility census was 86 residents. 1. Record review of Resident #78's Face Sheet showed he/she was admitted on [DATE], with diagnoses including high blood pressure, schizophrenia (a severe psychiatric disorder with symptoms of emotional instability, detachment from reality, and withdrawal into the self), diabetes, high potassium, amputation of the left breast, and high cholesterol. Record review of the resident's Care Plan dated 9/11/22, showed the resident had oral/dental health problems related to poor oral hygiene. Interventions showed staff would: -Administer medications as ordered and monitor/document for side effects and effectiveness. -Coordinate arrangements for dental care and transportation as needed/as ordered. -Provide the resident's diet as ordered. Consult with the dietitian and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to regularly reevaluate the discharge plan, involve the resident, address the resident's goals, and document that the resident had been asked about his/her interest in returning to the community for one sampled resident (Resident #77) out of 21 sampled residents. The facility census was 86 residents. Record review of the facility's policy, dated 2023, titled Protocol for Discharge Planning showed: -Residents were to be assessed for discharge potential upon admission, quarterly, and as needed. -Residents were to be assessed at least quarterly for the wish to discharge from the facility. -The Social Services Designee (SSD) was to conduct an interview with the resident and family on admission and quarterly for desire to discharge. 1. Record review of Resident #77's face sheet showed he/she was admitted [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe). 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.

Based on observation, interview, and record review, the facility failed to provide bathing and nail care assistance for a resident dependant upon staff for those cares for one sampled resident (Resident #12) out of 21 sampled residents. The facility census was 86 residents. Record review of the facility's policy, dated 2021, titled Policy for Daily ADL showed: -Staff were to assist and/or encourage the residents to perform ADLs. -Staff were to follow the care plan for each resident for instructions and preferences with ADL care. 1. Record review of Resident #12's face sheet showed he/she was admitted with the following diagnoses: -Chronic Kidney Disease, Stage 5 (kidneys are severely damaged and have stopped doing their job to filter waste from the blood; waste products may build up in the blood and cause other health problems). -Anxiety (feelings of fear, dread, and uneasiness that may occur as a reaction to stress). -Age related nuclear cataract, bilateral (these form in the middle of the lens of both eyes and cause the center to become yellow or brown, and is a major cause of…

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

Based on interview, and record review, the facility failed to maintain accountability of a controlled substance medication, Xanax (alprazolam is a benzodiazepine (antianxiety) medication used to treat anxiety and panic disorders) and to ensure a safe secure storage of controlled substance medications for one sampled resident (Resident #84) , out of 21 sampled residents. The facility census was 86 residents. Record review of the facility's policy titled Medication Administration and Monitoring, dated 2017, showed: -The nursing professionals and Certified Medication Technicians (CMT) were responsible to ensure accountability of medications during the change over of the shift. Record review of the facility's policy titled Management of Schedule II Medication, dated 2017, showed: -All controlled medication shall be checked and counted each shift by two licensed nursing staff. -Medication received by the pharmacy will be stored in the proper location by the licensed nurse. -Licensed nurse who received the medication shall count and document the values on the provided sheet. -Missing 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.

Based on interview and record review the facility failed to provided physician order anti-anxiety medication as prescribed for one sampled resident (Resident #84), who was without his/her anxiety medication for ten days, out of 21 sampled residents. The facility census was 86 residents. Record review of the facility's policy titled Medication Administration and Monitoring, dated 2017, showed: -Document by circle initials on the Medication Administration Record (MAR) if medication not administered and reason why. -Immediately notify the Director of Nursing (DON) and the resident's physician if not given two days in a row. -The nursing professionals and Certified Medication Technician (CMT) were responsible to ensure accountability of medication during the change over of the shift. Record review of the facility's policy titled Management of Schedule II medication, dated 2017, showed: -To ensure the safe practice and the compliance with the regulatory requirements. -The DON or designee licensed staff shall perform weekly checking and audit the controlled medication cart and records of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medications were stored in a locked compartment for two sampled residents (Resident #80 and Resident #77) out of 21 sampled residents. The facility census was 86 residents. Record review of the facility's policy, dated 2017, titled Policy for Non-Prescribing Medication and Self-Administration of Medication showed: -Residents who self-administered their own medication were to store the medication in a designated, locked, area of their room, or have the medication stored in the facility medication storage area. -Staff were to address placement of medications on the resident's care plan. 1. Record review of Resident #80's face sheet showed he/she was admitted with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD - a disease process that decreases the ability of the lungs to perform ventilation). Record review of the resident's undated care plan showed: -The resident had potential for injury related to non-compliance with…

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

Based on interview, and record review, the facility failed to assist one sampled resident (Resident #50) in obtaining routine and/or emergency dental care out of 21 sampled residents. The facility census was 86 residents. Record review of the facility's policy, dated 2017, titled Policy for Ancillary Services showed: -Staff were to arrange services for dental services once a recommendation was made for such services by any care provider. -Staff were to obtain a physician's order for dental services once a recommendation was made. -Staff were to arrange for the services to be completed. -Staff were to visit with the resident to address concerns and ensure dental needs were addressed on the care plan. 1. Record review of Resident #59's face sheet showed he/she was admitted with a diagnosis of End Stage Renal Disease (ESRD-a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). Record review of the resident's undated Care Plan showed staff did not…

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 include a section in the facility's visitor's food policy regarding labeling food that is brought in to residents by visitors with a date and the resident's name and to store food items (a ham/cheese sandwich, drinks, and sliced bread) with a resident's name and a date that the foods were brought in, in the 2nd floor resident use refrigerator. This practice potentially affected at least two residents who had foods stored in the 2nd floor refrigerator. The facility census was 86 residents. Record review of the facility's policy entitled Policy Regarding Use and Storage of Foods Brought to Residents by Family and Other Visitors dated 2019, showed: - Purpose: To be compliant with regulatory requirement to respect the resident's rights to accept food from outside resources. - The facility also is responsible for storing food brought in by family or visitors in a way that is either separate or easily distinguishable from facility food. - Ensuring safe food handling once the food is brought to the facility,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to close the lids of the outdoor dumpster while not in use and failed to close the lid to trash container that was next to the food preparation table, [NAME] it was not in use. This practice potentially affected the outdoor and the kitchen areas. The facility census was 86 residents. 1. Observation on 4/10/23 at 8:49 A.M., 9:52 A.M., 10:21 A.M., and 11:05 A.M., showed the lids of the outdoor dumpster were left open. Observation on 4/10/23 at 11:05 A.M., showed Dietary Aide (DA) B went outside with a bag of trash and placed it in the dumpster and left the lids open. Observation on 4/10/23 at 9:11 A.M., 10:21 A.M., 11:05 A.M., showed the trash container next to the food preparation table was left open. Observation on 4/10/23 at 12:35 P.M., showed the trash from the trash container overflowed onto the food preparation table. During an interview on 4/10/23 at 1:38 P.M., the Administrator said he/she expected all employees to close the dumpster after throwing…

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 follow a physician order for rehabilitative services and to notify the physician in a timely manner that rehabilitative services were not able to be provided for two sampled residents (Resident #39 and #72), so that alternate plans for receiving services could be initiated out of 21 sampled residents. The facility census was 86 residents. 1. Record review of Resident #39's Face Sheet showed he/she was admitted on [DATE], with diagnoses including stroke, high blood pressure, heart disease, and high cholesterol. Record review of the resident's significant change Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 2/28/23 showed the resident: -Was alert and oriented without confusion. -Was independent with transfer, mobility, toileting, needed supervision with eating and dressing and needed partial assistance with bathing. -Could ambulate, was unsteady on his/her feet but could…

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 offer or administer the pneumonia and influenza vaccine for one closed record sampled resident (Residents #87) out of 21 sampled residents out of five sampled residents for immunizations. The facility census was 86 residents. Resident Vaccination Policy was requested on 4/10/23 at 10:09 A.M. and 4/14/23 at 3:25 P.M., not received at time of exit. Record review of The Center for Disease Control (CDC) webpage, dated 2023, titled Adult Immunization Schedule by Age showed: -The influenza vaccine was to be given annually. -The pneumococcal vaccine was to be given to anyone age [AGE] or older. 1. Record review of Resident #87's admission Minimum Data Set (MDS-a federally mandated tool used for care planning), dated 6/23/22, showed the resident: -Had renal insufficiency (poor function of the kidneys). -Had a Brief Interview of Mental Status (BIMS) of 13 indicating the resident was cognitively intact. -Had received the influenza vaccine on 9/30/21. -Was…

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.