Gregory Ridge Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a functional and comfortable environment for residents by not maintaining inside resident room temperatures within acceptable parameters (71 to 81 degrees [ ] Fahrenheit [F] year-round) during outdoor temperature extremes in the event of a power outage and/or HVAC (heating, ventilation, and air conditioning) failure during those extremes; failed to develop a facility-specific, comprehensive climate control system outage policy and procedure; and failed to notify the proper agencies and entities of a failure in a timely manner, in accordance with State of Missouri rules and federal regulations. These deficient practices had the potential to affect all residents, visitors, volunteers, and staff who resided, visited, used, or worked in the facility. The facility census was 109 residents at the time of the investigation.Review of past Kansas City, Missouri outdoor temperatures on the Weather History website…

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 to the State Agency (SA) physical abuse for one sampled resident (Resident #2); when on 10/27/25 at approximately 12:00 P.M., Resident #1 approached Resident #2 from behind and struck him/her in the head and neck areas. Resident #2 was knocked to the floor and Resident #1 kicked him/her multiple times in the head and body out of 16 sampled residents. The facility census was 106 residents.Review of the facility's Abuse and Neglect Policy dated 6/12/24 showed:-Any owner, operator, employee, manager, agent or contractor of the facility can report an allegation of abuse/neglect/exploitation to the abuse agency without fear of retaliation.-Refer to the State Operations Manual (SOM) for reporting and utilize the Abuse-Neglect Reporting Decision Tree to assess the particular incident. Best practice was to include the SOM and Decision Tree with the investigation.-Should the incident be a reportable event, notify the appropriate agencies immediately; as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one sampled resident (Resident #8) out of 13 sampled residents, was free from misappropriation when facility staff Certified Nursing Assistant (CNA) A attempted to purchase and iPad from Resident #8 for $50. The facility census was 107 residents.On 6/5/25 the Administrator was notified of the potential failure and immediately began an investigation. The employee was placed on suspension pending the investigation. As a result of the investigation it was determined there was an attempt to engage in commerce and the employee was terminated. Training was completed on 6/10/25 for all staff related to the buying and selling of goods between staff and residents. Review of the facility Abuse and Neglect Policy dated 6/12/24 showed:-It is the policy of the facility to report all allegations of abuse/neglect/exploitation or mistreatment including injuries of unknown sources and misappropriation of resident property are reported immediately 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 maintain one sampled resident's (Resident #99) dignity when Receptionist A opened the resident's package without permission and then verbalized to another resident that the resident got him/her in trouble out of six sampled residents. The facility census was 115 residents. Review of the facility policy for Resident's Rights revised 7/5/23 showed: -Residents had the right to a dignified existence, self-determination and communication with access to persons and services inside and outside the facility. -The facility was to have promoted the rights of each resident. -Residents had the right to voice grievances without discrimination or reprisal. -Residents had the right to prompt communication and resolution to their grievances. Review of the facility's policy titled Dignity and Respect, revised on 6/29/23 showed: -Every resident had the right to be treated with dignity and respect. -All staff would speak to and treat all residents with dignity and…

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

Based on interview and record review, the facility failed to follow their facility policy by opening one sampled resident's (Resident #99 ) personal package without the resident's permission, causing the resident to be upset and angry that he/she was not allowed to open his/her own package out of six sampled residents. The facility census was 115 residents. Review of the facility policy for Resident's Rights revised 7/5/23 showed: -Residents had the right to a dignified existence, self-determination and communication with access to persons and services inside and outside the facility. -The facility was to have promoted the rights of each resident. -Residents had the right to voice grievances without discrimination or reprisal. -Residents had the right to prompt communication and resolution to their grievances. -Residents were to have been able to receive their mail promptly and unopened by facility staff. -Residents were to have been able to retain and use their personal possessions as space permitted. 1. Review of Resident #99's facility admission Record showed he/she was admitted…

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 residents were free from significant medication errors for one sampled resident (Resident #1). The facility failed to transcribe a physician's order for Eliquis (an anti-blood clotting medication) 5 milligrams (mg) twice a day (BID) orally (PO) from the resident's hospital discharge orders on 12/31/24 and subsequently failed to administer the medication as ordered out of four sampled residents. The facility census was 112 residents. Review of the facility's Transcription of Orders/Following Physician's Order policy revised on 5/18/24 showed: -The purpose of this policy was to outline procedures in accurately transcribing physician's orders and to ensure all physician's orders were followed. -Upon receiving a physician's order via telephone, fax, written order, transcribed order of other, it would be documented in the resident's electronic medical records (EMR) in the orders section. -If the medication is unable to be started within 24 hours 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.

Deficiency Text Not Available

Deficiency Text Not Available

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide timely de-escalation techniques for two sampled residents (Resident #9 and #43) with known mental health diagnoses out of 16 sampled residents. The facility census was 110 residents. Review of the Facility Assessment Tool dated 10/4/24 showed: -The facility accepts residents with Psychiatric/Mood Disorders, including: --Psychosis, Impaired Cognition, Mental Disorder, Depression, Bipolar Disorder, Schizophrenia, Post-Traumatic Stress Disorder, Anxiety Disorder, Behavior that needs interventions, Personality disorder, Schizoaffective Disorder, Explosive Disorder. -Psychosocial/Spiritual Supports include: --Building relationship with the residents and engagement in conversation. --Determine resident references and routines are; what makes a good day for the resident; what upsets the resident and incorporate the information into the care planning process. Ensuring staff have the information when providing are. The treatment and care…

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 store food in a manner that protected it from mice, failed to date items with the date opened, failed to perform hand hygiene, failed to store kitchen items on surfaces that were easily cleanable, failed to use clean gloves, and failed to maintain the sheet pan rack in a clean manner. These deficient practices had the potential to affect all residents, visitors, volunteers, and staff who ate food from the kitchen. The facility census was 111 residents. Review of the facility's policy titled Dietary-Equipment Operations, Infection Control, and Sanitation Policy dated as last reviewed on 2/2/24 showed: -Tray carts should be washed and sanitized after each meal. -The policy did not address handwashing, glove use, food storage, and storage of items on surfaces that were not easily cleanable. 1. Observation on the initial kitchen tour on 12/16/24 at 12:19 P.M. showed: -Large, opened bags of rice and brown sugar were under the main storage prep table, were not closed or in containers, and they were not dated 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an effective pest control program for four sampled residents (Resident #108, #43, #23 #35) out of 23 sampled residents, so that the facility remained free of pests and rodents. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who reside in or visit the facility. The facility census was 111 residents. Review of the facility's policy titled Pest Control Program Policy dated 5/14/24 showed: -It was the policy of the facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. -Effective pest control program was defined as measures to eradicate and contain common household pests including mice. 1. Review of the facility pest control invoices showed: -On 9/24/24 - one mouse caught on a trap. -On 10/1/24 - discovered rodent activity at bait stations. -On 11/5/24 - found rodent activity around back side of building. -On 11/19/24 -…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to promote dignity for three sampled residents (Resident ##66, #78, and #98) by entering their room without knocking out of 23 sampled residents. The facility census was 111 residents. Review of the facility's policy Dignity and Respect revised 6/29/23 showed: -The facility was to ensure every resident was treat with dignity and respect. -Every resident had the right to be treated with dignity and respect. Review of the facility's policy Resident Rights revised 7/5/23 showed: -The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The facility must protect and promote rights of each resident. -Personal privacy include accommodations, medical treatment written and telephone communications, personal care, visits, and meetings of family and resident groups. 1. Review of resident #66's admission Record showed he/she was initially admitted 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 prevent commingling (the mixing of funds belonging to one person with funds belonging to another) of resident funds with any person other than the resident by allowing negative balances in the resident trust fund account for six supplemental residents (Residents #53, #58, #79, #100, #167 and #169) sampled for resident trust funds review and failed to complete or maintain reconciliation of the resident trust fund account to the bank statements. This deficient practice had the potential to affect all residents who have a resident trust fund. The facility census was 111 residents. Review of the facility's policy titled Resident Trust dated as reviewed on 2/2/24 showed: -Resident trust fund money would be safeguarded by the facility, using complete and separate accounting principles and prevent commingling of resident funds. -The facility shall keep an accurate and maintained accounting system for the residents that choose to have their personal funds…

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 privacy for residents who wished to use the facility telephone for two sampled residents (Resident #19, Resident #112) out of 23 sampled residents. This had the potential to affect all residents who used the telephone in the facility. The facility census was 111 residents. Review of the facility's policy, Resident Rights, dated 7/5/23 showed: -Residents were to have been treated with consideration, respect, and in full recognition of his/her dignity and individuality, including privacy and in care for his/her personal needs. -The resident has the right to have reasonable access to the use of a telephone where calls could have been made without being overheard. --The policy included an undated handwritten notation use of phone if want privacy - may use administrator work phone. Plans to move the phone to Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning) office for medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the right to open mail privately for two sampled residents, (Resident #99 and #14) out of 23 sampled residents. This potentially affected all residents who receive mail at the facility. The facility census was 111 residents. Review of the facility's policy, Resident Rights, dated 7/5/23 showed: -Residents were to have been treated with consideration, respect, and in full recognition of his/her dignity and individuality, including privacy and in care for his/her personal needs. -The resident has the right to have reasonable access to the use of a telephone where calls could have been made without being overheard. 1. Review of Resident #99's Quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility staff for care planning) dated 11/22/24 showed he/she was cognitively intact. During an interview on 12/20/24 at 2:15 P.M., the resident said: -He/She can't open his/her mail privately. -The activity…

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 residents had a safe homelike environment by not ensuring the ceiling tiles were not damaged, the floor tiles were not damaged, the ceiling did not leak, failed to ensure there was not mouse excrement on the floor, for five sampled residents, (Resident #108, #23, #25, #102, #72) and for one supplemental resident (Resident #43) out of 23 sampled residents and 12 supplemental residents. The facility failed to ensure the medication room on the Men's Locked Unit was kept clean and hand hygiene products were available for staff. The facility census was 111 residents. Policy requested and not provided by the end of survey. 1. Review of Resident #108's Face Sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 11/20/24 showed he/she was cognitively intact. Observation 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 interview and record review, the facility failed to ensure residents were seen by a physician at least every 30 days for the first 90 days and then at least every 60 days thereafter for three sampled residents (Resident #9, #108, and #107 ) out of 23 sampled residents. The facility census was 111 residents. 1. Review of Resident #9's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Impulse disorder (a psychiatric condition that makes it difficult to control actions or reactions). -Borderline intellectual functioning (below average cognitive functioning). -Schizophrenia (a chronic mental illness that interferes with a person's ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions, and relate to others). -Bipolar (mood disorders characterized usually by alternating episodes of depression and mania). -Anxiety Disorder (a psychiatric disorder causing feelings of persistent anxiety). -Post-Traumatic Stress 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.

Based on interview and record review, the facility failed to ensure staff, residents and visitors had access to daily staffing by not posting staffing data in a prominent and readily accessible area for all residents to have access. The facility census was 111 residents. Review of the facility's Nurse Staffing Posting Information Policy, dated 6/26/24, showed: -The purpose of the policy was to make sure nurse staffing information was readily available in a readable format to resident's and visitors at any given time. -The nurse staffing sheet was posted daily and contained: --The facility name. --Current date. --Current resident census. --Total number and actual hours worked by Registered Nurses (RN), Licensed Practical Nurses (LPN), Certified Nursing Assistants (CNA). -The facility posted the Nurse Staffing sheet at the beginning of each shift. -It was in a prominent place readily accessible to residents and visitors. Observation on 12/16/24 at 12:05 P.M. showed a wipe board hanging in the lobby of the facility which displayed the date, and number of people working by title CNA,…

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 Narcotic (a substance used to treat moderate to severe pain) medication count was correct, and failed to ensure that two nursing staff were counting the narcotics at the beginning and end of each shift. The facility census was 111 residents. Review of the facility's Administration and Accountability Policy, dated 5/14/24 showed: -All controlled substances were accounted for in the following ways: -All controlled substances obtained were recorded on the designated usage form. -Written documentation must be clearly legible with all applicable information provided. -The controlled Drug Record serves the dual purpose of recording both narcotic disposition and patient administration. -The Charge nurse or other designee should have conducted a daily visual audit of the required documentaion of controlled substances. -For patient care areas which do not utilize an automated dispensing systems the amount on hand was to have been checked against the amount used daily from the documented records. -Two licensed nurses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident was free from unnecessary medications and recommendations were addressed by the physician in a timely manner for four sampled residents (Residents #9, #108 and #19 and failed to ensure a medication that was prescribed had an associated diagnosis for one sampled resident (Resident #25) out of 23 sampled residents. The facility census was 111 residents. Review of the facility's Medication Regimen Review (MRR) policy dated 6/24/24 showed: -The drug regimen review should be completed by the pharmacist at least monthly. -Facility staff shall act upon the recommendations. 1. Review of Resident #9's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Impulse disorder (a psychiatric condition that makes it difficult to control actions or reactions). -Borderline intellectual functioning (below average cognitive functioning). -Schizophrenia (a chronic mental illness that interferes with a person's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident was free from unnecessary psychotropic medications for five sampled residents (Residents #9, #108, #66 #102, and #7) out of 23 sampled residents. The facility census was 111 residents. Review of the facility's Gradual Dose Reduction of Psychotropic Drugs updated 5/14/24, showed: -Residents who use psychotropic drugs received gradual dose reductions and behavioral interventions, unless clinically contraindicated, to discontinue those drugs. -Psychotropic drugs were defined as any drug that affects the brain activities associated with mental processes and behaviors. -Psychotropic drugs included but were not limited to the following categories: antipsychotics, antidepressants, antianxiety, and hypnotics. -Rationale for clinical contraindications may be documented in the electronic health record. -A GDR will be attempted annually unless clinically contraindicated. 1. Review of Resident #9's Face Sheet showed he/she was admitted to the…

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

Based on observation, interview and record review, the facility failed to dispose of garbage and refuse properly by having a roll-off dumpster and the surrounding area over-flowing of trash, equipment, and furniture. The facility census was 111 residents. The facility did not have a policy related to this deficiency. 1. Observation on 12/16/24 at 8:30 A.M., 12/17/24 at 8:30 A.M., 12/18/24 at 10:00 A.M., 12/18/24 at 11:06 A.M., 12/18/24 at 1:08 P.M., and 12/19/24 at 9:55 A.M., showed: -One dumpster with two closing lids in the facility's south-east parking lot. -A roll-off dumpster north of the other dumpster in the facility's south-east parking lot. -The roll-off dumpster: --Was 23 feet in length, 7 feet in width, and 4 feet in height. --Was completely full of about two layers of trash bags visible over the top of the dumpster. --There were two bags of trash in front of the dumpster on the ground and a bag of trash on the ground on the north-east side of the dumpster. --There were two toilets, two mattresses, an office chair, multiple wood boards from broken furniture, four wood…

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 12 hours of nurse aide in-service training that included the topics of dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses), and Abuse, Neglect and Exploitation (ANE) for four out of five sampled Certified Nursing Assistants (CNA) (CNA A, CNA B, CNA E and CNA G) for January 2024 through December 2024. The facility census was 111 residents. Review of the facility's Nurse Aide (NA) Training Program Policy, dated 5/18/24, showed: -The purpose of the policy was to maintain appropriate and effective NA in-service training, ensuring the continue competence of nurse aides. -The facility and the Director of Nursing (DON) were responsible for the coordination and/or provision of NA education. -Each NA was provided at least 12 hours of in-service training annually. -The facility maintained documentation of training.…

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 written invitations and hold care plan meetings to ensure resident focused person-centered care for one sampled resident (Resident #26) out of 23 sampled residents. The facility census was 111 residents. Review of policy Comprehensive Care Plans revised 10/31/24 showed: -The facility was to develop and implement a comprehensive person-centered care plan for each resident consistent with resident rights that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the resident's comprehensive assessment. -Person-centered care means to focus on the resident as the focus of control and support the resident in making their own choices and having control over their daily lives. -The care planning process would include an assessment of the resident's strengths and needs and would incorporate the resident's personal and cultural preferences in the development 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 a resident was able to purchase items his/her family and/or guardian provided money to purchase in a timely manner for one sampled resident (Resident #108) out of 23 sampled residents. The facility census was 111 residents. 1. Review of Resident #108's face sheet showed he/she was admitted to the facility on [DATE] and he/she had a guardian. Review of the resident's Progress Notes dated 11/6/24 showed: -He/She had been in the administrator's office asking if the funds to purchase a tablet and earphones had been received. -No further documentation related to the resident's funds or the status of purchasing a tablet and earphones. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 11/20/24 showed he/she: -Was cognitively intact. -Had physical, verbal, and other behaviors 1-3 days during the lookback period. Review of the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy by failing to provide the resident with an up-to-date accounting of his/her trust account balance and return the resident's funds timely for one supplemental resident (Resident #168) out of three supplemental residents sampled for discharged residents. The other two residents sampled had negative balances. The facility census was 111 residents. Review of the facility's policy titled Resident Trust reviewed on 2/2/24 showed: -Upon discharge, the facility shall provide an up-to-date accounting of the resident's trust account balance. -The resident shall be issued a check for all remaining personal funds in his/her account within five days of discharge. 1. Review of Resident #168's trust statement through 9/30/24 showed a balance of $2,406.51. Review of the facility's list of residents with a resident trust fund account discharged for the past three months dated 12/16/24 showed the resident discharged to home on [DATE]. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review ,the facility failed to complete a thorough investigation for an allegation of employee to resident abuse and resident to resident abuse on 12/8/24 for two sampled residents (Resident #9 and #89) out of 23 sampled resident. The facility census was 111 residents. Review of the facility's Abuse and Neglect policy dated 1/3/23 showed: -Employees are trained through orientation and ongoing training on issues related to abuse prohibition practices such as dealing with aggressive residents, and recognizing signs of burnout, frustrations, or stress that may lead to abuse. -On a regular basis, supervisors will monitor the ability of staff to meet the needs of residents and staffs understanding of individual resident care needs. Situations such as inappropriate language, insensitive handling, and impersonal care will be corrected as they occur. -An investigation will include assessment of all residents involved and interventions to ensure protective oversight of all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the resident and/or the resident's representative(s) of a transfer to a nursing facility, including the reasons for the transfer in writing for two sampled residents (Residents #116 and #115) and failed to notify the Ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) of the discharge for one sampled resident, (Resident #115), out of two closed record sampled residents. The facility census was 111 residents. Review of the policy Resident Transfer/Discharge, Immediate Discharge, and Therapeutic Leave revised date of 5/14/24 showed: -The transfer referred to the movement of a resident from a bed in one certified facility to a bed in another certified facility when resident expects to return to the original facility. -Notice of Discharge or Transfer: --Who must receive notice. ---Notify the resident and the resident representative the reason for the transfer or discharge in…

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 assess the resident's dental status on the resident's Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) on one sampled resident (Resident #27) out of 23 sampled residents. The facility census was 111 residents. Review of the facility's policy titled MDS 3.0, Care Assessment Summary and Individualized Care Plans dated as revised on 11/6/23 showed: -The purpose of the policy was to ensure that MDS 3.0 sections were completed accurately and in a timely manner by the assigned responsible parties. -The MDS addressed the holistic person, including functional status, quality of life and individual plan of care to address and meet the needs of the individual resident. -The MDS must be kept current and up to date. 1. Review of the Resident #27's admission MDS dated [DATE], showed: -The resident was cognitively intact. -The resident had no missing teeth or issues with his/her teeth.…

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 develop a comprehensive person-centered care plan for two sampled residents (Residents #27 and #72) out of 23 sampled residents. The facility census was 111 residents. Review of the facility's policy titled Comprehensive Care Plans dated as revised on 10/31/24 showed: -The facility staff would develop and implement a comprehensive, person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. -The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning) assessment. 1. Review of Resident #72's admission MDS dated [DATE], showed: -The resident was admitted to the facility on [DATE]. -The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure medications that were prescribed by the physician were administered within the time frame the physician had ordered for one sampled resident (Resident #12) out of 23 sampled residents. The facility census was 111 residents. Review of the facility's policy, Medication Administration Policy, dated 6/26/24 showed: -Medications were to have been administered by licensed nurses, or other staff who were legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. -Ensure that the six rights of medication administration were followed: -Right resident. -Right drug. -Right dosage. -Right route. -Right time. -Right documentation. -Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. 1. Review of Resident # 12's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Paranoid Schizophrenia (a mental…

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 complete a comprehensive discharge summary for one sampled resident (Resident #116) out of two sampled closed discharge record. The facility census was 111 residents. Review of the facility's policy, Resident Transfer/Discharge, Immediate Discharge and Therapeutic Leave Policy, dated 5/14/24 showed: -The purpose of the policy was to establish policy and procedure regarding the transfer/discharge of residents. -When a resident is discharged or transferred the interdisciplinary discharge summary (recapitulation) must be completed in Point Click Care. -When a resident is transferred or discharged , the resident's attending physician must document in the medical record with the reason for the transfer/discharge. 1. Review of Resident #116's admission Record showed: -The resident was admitted to the facility on [DATE]. -The resident was discharged /transferred to another facility on 9/17/24. -The resident was his/her own responsible party. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to establish a communication device for one sampled resident, (Resident #66) to improve the ability to carry out activities of daily living related to communication out of 23 sampled residents. The facility census was 111 residents. Review of the facility's Activities of Daily Living (ADL) policy revised 5/18/24 showed: -The facility would, based on the resident's comprehensive assessment and consistent with the resident's needs and choices ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. --Care and services would be provided for the following activities of daily living: ---Using speech, language, or other functional communication systems. -Tips for improving or maintaining ADL skills. -Evaluating reason for decline in ADL skills. 1. Review of resident #66's admission Record showed he/she was admitted [DATE] with the diagnoses to include: -Malignant neoplasm of the laryngeal cartilage (a cancerous…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #51) was seen by a Dermatologist out of 23 sampled residents. The facility census was 111 residents. Policy requested from the facility and was not provided. 1. Review of Resident #51's admission Record showed: -He/She was admitted to the facility on [DATE]. -He/She had a guardian. Review of the resident's quarterly Minimum Data Set (MDS) dated [DATE] showed: -He/She was moderately cognitively impaired. -Other skin problems was not checked. Observation and interview of the resident on 12/17/24 at 10:25 A.M. showed: -He/She had a golfball sized cyst on the left side of his/her face. -The cyst bothers him/her and should have been taken care of months ago. -He/She said that there was a physician's appointment this fall but there was a problem with the transportation to the appointment and he/she did not go to the appointment. -Nursing staff said someone should have rescheduled the appointment but 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 interview and record review, the facility failed to ensure weekly skin and/or wound assessments were completed each week for one sampled resident (Resident #21) out of 23 sampled residents. The facility census was 111 residents. A policy for skin and wound assessments was requested but not received at the time of exit. 1. Review of Resident #21's Face Sheet showed he/she had a diagnosis of a left heel Stage III wound (a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) with a diagnosis onset date of 9/30/24. The resident also had a diagnosis of diabetes. Review of the resident's Braden Risk Assessment (a tool used to predict the likelihood of developing a pressure ulcer) dated 6/11/24 score was 21 indicating the resident was not at risk for developing pressure ulcers. Review of the resident's Clinical admission note dated 9/19/24 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 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) were cleaned and stored in a sanitary condition for two sampled residents, (Resident #72 and #27) out of 23 sampled residents. The facility census was 111 residents. Review of the facility's policy, Oxygen Administration, dated 5/18/24 showed: -The facility was to follow the manufacturer recommendations for the frequency of cleaning oxygen equipment and filters. -Change oxygen tubing and mask, cannula (a medical device that provides supplemental oxygen to patients through two prongs that fit into the nostrils) weekly and as needed if it becomes soiled or contaminated. -Keep delivery devices covered in plastic when not in use. 1. Review of Resident #72's admission Record showed: -The resident was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the physician was notified of abnormal laboratory values for one sampled resident, (Resident #19) out of 23 sampled residents. The facility census was 111 residents. Review of the facility's policy, Diagnostic Testing Services Policy, dated 6/26/24 showed: -The facility would provide the appropriate diagnostic tests in accordance with the physician's orders. -Qualified nursing personnel would have received and reviewed the diagnostic test reports and communicated the results to the ordering physician within 24 hours of receipt unless the report results fall outside of clinical reference ranges and required immediate attention at which time the physician would have been notified upon receipt. 1. Review of Resident #19's face sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of bipolar disorder (a mental disorder characterized by manic highs (highly excited, over active and distracted), and lows (feelings of depression).…

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 routine and/or emergency dental services to meet the needs of residents were offered to two sampled residents, (Residents #26 and #98), out of 23 sampled residents. The facility census was 111 residents. Review of the facility's policy Dental Services dated 6/26/24 showed: -It is the policy of the facility to assist residents in obtaining routine and emergency dental care. -Routine dental services means an annual inspection of the oral cavity for signs of disease, diagnosis of dental disease, minor partial or full denture adjustments, and limited prosthodontic procedures such as taking impressions for dentures and fitting dentures. -Oral care and denture care shall be provided in accordance with identified needs and as specified in the plan of care. -The Social Services Director (SSD) would maintain contact information for providers of dental services that are available to facility residents. 1. Review of Resident #26's admission…

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 2. Review of Resident #201's admission record showed he/she was admitted on [DATE] and readmitted on [DATE] with the following diagnoses: -Anxiety Disorder, 12/10/24. -Restlessness (a feeling of unease, or an inability to stay still) and Agitation (the state of anxiety or nervous excitement) 12/10/24. -Unspecified Intellectual disabilities (significant limitations in reasoning, learning, problem solving and also adaptive behavior which covers a range of everyday social and practical skills) 12/10/24. Review of the resident's Quarterly MDS, dated [DATE], showed: -He/She was cognitively intact. -Had physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing,) occurred one to three days in the seven-day look back. -Had verbal behavioral symptoms directed toward others (e.g., threatening, screaming, cursing directed toward others) occurred one to three days in the seven-day look back. -Had other behavioral symptoms not directed toward others e.g. physical symptoms such…

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 appropriately de-escalate one sampled resident with known triggers and mental health needs (Resident #9). On 8/6/24, the resident displayed behaviors of agitation, yelling, throwing items, kicking, hitting the wall, nightstand and mattress. Staff failed to provide calm redirection; decrease stimulation; use a firm and calm approach; and avoid getting into a power struggle with the resident. Staff argued with the resident, became defensive, called the resident derogatory names, and failed to respect his/her personal space. Staff failed to utilize de-escalation techniques appropriately and to involve the interdisciplinary team and guardian per the resident's care plan. The resident was not encouraged to express emotions in a safe environment. Rather, facility staff left the resident alone with Licensed Practical Nurse (LPN) G in his/her room after LPN G called off a Code [NAME] and said he/she would handle it him/herself- and proceeded to kick, slap 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 ensure Resident #29's belongings were sent to the resident's current facility after discharging from the facility on 2/8/24. This affected one out of 34 sampled residents. The facility census was 109 residents. Review of the facility's policy, Resident Transfer/Discharge, Immediate Discharge, and Therapeutic Leave Policy, dated 5/14/24, showed: -Transfer and Discharge includes movement of a resident to a bed outside of the certified facility whether that bed is in the same physical plant or not. -Discharge refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility or other location in the community, when return to the original facility was not expected. -The facility should provide sufficient preparation and orientation to ensure that the resident has a safe and orderly transfer or discharge. -This includes informing the resident where he or she was going and taking steps to minimize anxiety. 1.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #9) was free from abuse. On 7/12/24 a Certified Nursing Assistant (CNA) E pushed the resident into a corner and pinned him/her so he/she could not move out of 26 sampled residents. The facility census was 109 residents. On 7/24/24, the facility Administration was notified of the past noncompliance which occurred on 7/12/24. Facility staff were educated on abuse and neglect protocols and customer service. The deficiency was corrected on 7/14/24. Review of the facility's Abuse and Neglect Policy, reviewed and revised on 6/12/24, showed: -Abuse was defined as a willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. -Physical abuse included handling a resident with any more force than was reasonable for a resident's proper control, treatment, or management. -Mistreatment was inappropriate treatment or exploitation of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free from significant medication errors for two sampled resident (Resident #12 and Resident #13) out of 26 sampled residents. The facility census was 109 residents. Review of the facility's Medication Administration dated 4/6/17, revised on 6/26/24 and Reordering policy dated 5/18/24 showed: -Medications are to be given per doctor's orders. -All medications are recorded on the Medication Administration Record (MAR) and signed immediately after the resident has taken the medications. -The nurse or Certified Medication Technician (CMT) will check each medication to the MAR noting the correct name of the medication, correct resident name, correct dose, correct time, and correct route of administration. -Report and document any adverse side effects or if the medication is refused. -Correct any discrepancies and report to nurse manager. -To accurately and safely provide or obtain pharmaceutical services including the provision 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 keep one sampled resident (Resident #5) free from physical abuse when on 6/26/24 the facility Dietary Manager (DM) hit the resident in the head out of 9 sampled residents. The facility census was 110 residents. On 6/27/24, the facility Administration was notified of the past noncompliance which occurred on 6/26/24. Facility staff were educated on abuse and neglect protocols and customer service. The deficiency was corrected on 6/26/24. Review of the facility policy titled, Behavioral Emergency Policy, revised 1/5/23 showed: - Provide safe treatment and humane care to the resident in a behavioral crisis to outline steps to follow to correctly care for the resident in a behavioral crisis, to ensure that the resident is not being coerced, punished or disciplined for staff convenience. Review of the facility policy titled, Abuse and Neglect Policy, revised 4/30/24 showed: -Mistreatment, neglect, or abuse of residents is prohibited by the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure there was appropriate documentation in the medical record for one sampled resident (Resident #2) related to his/her transfer and discharge out of seven sampled residents. The facility census was 108 residents. 1. Review of Resident #2's Pre admission Screening and Resident Review (PASRR-a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) dated 10/22/21, showed: -The resident was evaluated for placement in a long term care nursing facility. -Public Administrator was the resident's legal guardian. -The resident had psychiatric symptoms of delusions, hallucinations, paranoia, disorganized thoughts, agitation, irritability and was uncooperative with cares. -The resident had persistent psychosis despite changes in antipsychotic medications and continued to experience paranoia, disorganized thoughts and manipulative behavior regarding taking medications. -The resident had multiple…

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 sampled resident (Resident #2) or his/her guardian received a notice of the bed hold policy out of 7 sampled residents. The facility census was 108 residents. Review of the facility Bed Hold policy and procedure dated 7/27/2018, showed: -When a resident is admitted to the facility, they receive a copy of the bed hold policy. -When a resident is discharged to the hospital or goes on therapeutic leave, the facility will provide to the resident or legal representative, a copy of the bed hold policy. -Following a hospitalization or therapeutic leave, the resident will be admitted if they require the services of the facility and is eligible for Medicare or Medicaid services. -When a resident is admitted to the facility following a hospitalization or therapeutic leave and did not have a bed hold or exceeds the bed hold days, the resident will be returned to their previous room if available. If their previous room is not available, they should be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility staff failed to report physical abuse for one sampled resident (Resident #23). Facility staff Housekeeper B, Hall Monitor C, Certified Nursing Assistant Aide (CNA) D, Dietary Aide A, Licensed Practical Nurse (LPN) A and Certified Medication Technician (CMT) A watched the abuse and did not make a report. The facility census was 109 residents. On 4/23/24, the facility Administration was notified of the past noncompliance which occurred on 4/14/24. Facility staff were educated on Elder Justice Reporting Requirements. The deficiency was corrected on 4/15/24. Review of the facility's policy titled Abuse and Neglect Policy dated 1/5/23 showed: -Physical abuse was purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane way. -The facility was committed to protecting the residents from abuse by anyone including, but not limited to, facility staff, other…

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 a resident with an appropriate discharge plan before an immediate involuntary discharge when one sampled resident (Resident #2) was transferred to the hospital and not allowed to return to the facility out of three sampled residents. The facility census was 112 residents. Record review of the facility's Resident Transfer/Discharge, Immediate Discharge, and Therapeutic Leave Policy, dated 7/12/22, showed: -A facility-initiated transfer or discharge was a transfer or discharge which the resident objected to, which did not originate through a resident's verbal or written request, and/or was not in alignment with the resident's stated goals for care and preferences. -Discharge referred to the movement of a resident from a bed in one certified facility to a bed in another certified facility or other location in the community when return to the original facility was not expected. -The facility could discharge or transfer a resident as 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 prevent abuse for three sampled residents (Resident's #19, #10 and #11). On [DATE] Resident #19 pushed Resident #20 and then punched him/her in the face, resulting in a blackened left eye. On [DATE] Resident #10 and Resident #11 hit and scratched each other resulting in bruising to Resident #11's left upper posterior arm and superficial scratches on Resident #10's face and neck out of 19 sampled residents. The facility census was 113 residents. Review of the facility policy titled, Abuse and Neglect Policy, dated [DATE] showed: -The facility was committed to protecting residents from abuse by anyone. -Physical Abuse was purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or humane manner. 1. Review of Resident #19's PASSR (Preadmission Screening and Resident Review - a federally mandated screening process for individuals with serious mental illness…

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 immediately investigate a resident to resident altercation that occurred on [DATE] between two sampled residents (Resident #10 and #11) out of 19 sampled residents. The facility census was 113 residents. Review of the facility policy titled, Abuse and Neglect Policy, dated [DATE] showed: -The facility must ensure that all alleged violations involving abuse were reported immediately, but no later than 2 hours after the allegation was made, if the events involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse or result in serious bodily injury, to the State Survey Agency. -If the abuse involved alleged suspicion of a crime, it must also be reported to local law enforcement within those time frames. -Upon learning of the report of abuse or neglect, the Administrator should initiate an incident investigation. The staff were additionally responsible for reporting 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 provide adequate supervision and coordination for resident transfer for one sampled resident (Resident #4). On 1/3/24 at approximately 11:50 P.M., the resident returned from the hospital and there was no staff at the door to receive the resident resulting in him/her walking away unescorted from the facility out of 19 sampled residents. The facility census was 113 residents. On 1/29/24, the facility Administration was notified of the past noncompliance which occurred on 1/3/24. Facility staff were educated on elopement protocols, customer service and coordination of transfer. The deficiency was corrected on 1/5/24. Review of the facility policy titled, Elopement Protocol, dated 1/19/22 showed: -An elopement will be defined as any time a resident is missing from the facility or there is a possibility that a resident has left the facility without appropriate supervision and their whereabouts are unknown. -The first person aware of an elopement will call a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the facility staff had the competencies and skills to assure resident safety for one sampled resident (Resident's #9) when on 1/12/24 Licensed Practical Nurse (LPN) A failed to monitor the resident closely after a behavior crisis and Hall Monitor A failed to use proper Crisis Alleviation Lessons and Methods (CALM) technique during the resident's behavioral crisis out of 19 sampled residents. The facility census was 113 residents. On 1/29/24, the facility Administration was notified of the past noncompliance which occurred on 1/12/24. Facility staff were educated on customer service, Elder Justice Reporting Requirements, Code [NAME] and CALM techniques and behavioral health interventions. The deficiency was corrected on 1/17/24. Review of the facility policy titled, Behavioral Emergency, dated 1/5/24, showed: -To provide safe treatment and humane care to the Resident in a behavioral crisis, to outline steps to follow to correctly care for 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 staff failed to maintain residential areas in a repaired, clean and in a sanitary manner, specifically in areas of toilet rooms and resident rooms, for three sampled residents (Resident's #2, #39 and #108) out of 23 sampled residents. The facility census was 111 residents. 1. Record review of Resident #108's undated admission Record showed he/she was admitted to the facility on [DATE] and was his/her own responsible party. -Had the following diagnoses: - -Hypertension (blood pressure that is higher than normal). - -Gastroesophageal Reflux Disease (GERD - a common condition in which the stomach contents move up into the esophagus toward your mouth, automatically as a reflex or burp). - -Urinary Tract Infection (common infections that happen when bacteria, often from the skin or rectum, enter the urethra, and infect the urinary tract or cause a bladder infection). Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated…

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 accurately code the Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning) for six sampled residents (Resident's #86, #47 #2 #31, #21,and #61) out of 23 sampled residents. The facility census was 111 residents. Review of facility policy MDS 3.0, Care Assessment Summary and Individualized Care Plans revised 2/6/2021 showed: -Sections of the MDS should be completed accurately and in a timely manner by the assigned responsible parties. 1. Record review of Resident # 86' s quarterly MDS dated [DATE] showed the resident was marked yes to further evaluate for BIMS (BIMS-brief interview for mental status score) to determine his/her cognitive status and this was not completed. 2. Record review of Resident #2's quarterly MDS dated [DATE] showed the resident was marked yes to further evaluate for BIMS (BIMS-brief interview for mental status score) to determine his/her cognitive status and this 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 ensure the follow-through of the Pre-admission Screening and Resident Review (PASRR-a federal program implemented in 1987 to: Prevent individuals with mental illness (MI), intellectual disability (ID) or related conditions (RC) from being inappropriately placed in a Medicaid certified nursing facility (NF) for long-term care) recommendations and to integrate the recommendations into the care plan for four sampled residents (Resident #61, #76, #54, and #55) out of 23 sampled residents. The facility census was 111 residents. 1. Record review of resident #61's PASRR dated 6/12/19 showed the resident: -Had irritability, elevated anxiety, depressed mood, perseverated though processes, hostility toward a family member including threatening to kill him/her, auditory hallucinations, self-harm acts, bizarre behavior of eating non-food items, history of cutting self, disorganized thinking, and substance abuse issues. -The resident required a line 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 a comprehensive care plan was developed and implemented for five sampled residents (Resident #86, #47, #2, #91, and #76) out of 23 sampled residents. The facility census was 111 residents. Record review of facility Policy and Procedure Minimum Data Set (MDS - a federally mandated assessment tool required to be completed by facility staff for care planning purposes) Care Assessment Summary and Individualized Care Plans revised 2/26/21 showed: -All CAT (Care Area Assessment Triggers) must be addressed in the individualized plan of care for residents. 1. Record review of Resident #86's Face Sheet showed he/she was admitted to the facility on [DATE]. Record review of the resident's 3/24/23 quarterly MDS showed current tobacco use was not marked. Record review of the resident's Nurse Practitioner note dated 3/27/23 showed resident with a smoking history for the past seven years. Record review of the resident's care plan dated 4/4/23…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow professional standards of practice related to documentation of medications administration for six sampled residents (Residents #12, #24, #61, #16, #108, and #1) out of 23 sampled residents. The facility census was 111 residents. Record review of facility policy entitled Transcription of Orders/Following Physician's Orders dated 4/6/17 last revised 7/9/21 showed: -The Unit Director/Designated Nurse would review all Medication Administration Records (MAR) and Treatment Administration Records (TAR) daily to monitor for medications that were not administered to a resident. -The nurse or Certified Medication Technician (CMT) in charge of medication administration must have reviewed all the designated MARs and TARs prior to the end of the shift and ensured that all medications and treatments scheduled to be given on the shift were administered according to the physician's order and that all necessary interventions were took in the event…

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 identify, assess and provide supportive interventions for three sampled residents (Resident #61, #76, and #91), with a diagnosis of Post-Traumatic Stress Disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event), out of 23 sampled residents. The facility census was 111 residents. Record review of Trauma-Informed Care Implementation Center (https://www.traumainformedcare.chcs.org/what-is-trauma-informed-care/) copyright 2021 showed: -Trauma-informed care shifts the focus from What's wrong with you? to What happened to you? -A trauma-informed approach to care acknowledges that health care organizations and care teams need to have a complete picture of a patient's life situation - past and present - in order to provide effective health care services with a healing orientation.…

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 adequately assess, monitor, document and provide treatment that includes ongoing appropriate interventions for target behaviors; to ensure supportive services were in place and to have an individualized care plan based on the resident's behaviors for three sampled residents (Resident #61, #76, and #91) out of 23 sampled residents. The facility census was 111 residents. A policy for behaviors was requested and was not received by the facility. 1. Record review of Resident #61's admission Record showed the resident: -Was admitted to the facility on [DATE]. -Had the following diagnoses: --Borderline Personality Disorder (BPD-a mental illness marked by an ongoing pattern of varying moods, self-image, and behavior). --Obsessive-Compulsive Disorder (OCD) an anxiety disorder characterized by intrusive thoughts that produce uneasiness, apprehension, fear, or worry; by repetitive behaviors aimed at reducing the associated anxiety; or by a combination of such…

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 sampled resident (Resident #108), who was his/her own legal representative, out of 23 sampled residents had his/her code status preferences accurately reflected on his/her admission Record, Code Status Care Plan, and Physician Orders to accurately reflect the resident's choice at the time of his/her admission. The facility census was 111 residents. Record review of the facility's Advanced Directives (AD - a legal document that states a person's wishes about receiving medical care if the person is no longer able to make medical decisions because of a serious illness or injury) policy/procedure, updated [DATE] showed: -At the time of admission, the resident will be provided with written information concerning the resident's rights under state law, to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advanced directives. This information will be provided by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow physician orders for surgical wound care and treatment to the resident's left buttock wound, document in the resident's Treatment Administration Record (TAR) that wound treatments had been completed as ordered by the physician and document all surgical wounds on the facility weekly skin assessment for one sampled resident (Resident #2) out of 23 sampled residents. The facility census was 111 residents. Record review of the facility policy and procedure for Wound Management revised on 4/9/21 showed: -Treatments will be set up per physician's order. -Any deviance from set protocols must be approved by physician. Record review of the facility policy and procedure for Following Physician Orders revised on 7/9/21 showed: -The designated nurse will review all Treatment Administration Records (TAR) daily to monitor for treatments that were not administered to the resident due to unavailability, refusal, omission, etc. -Anytime a treatment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one sampled resident (Resident #21) was assessed to be able to self- care for an ileostomy (a surgical operation in which a piece of the small intestine is diverted to an artificial opening in the abdominal wall to remove body waste-feces), and to monitor the ileostomy site and to ensure that one sampled resident (Resident #2) had appropriate treatment and services for nephrostomy tube (a tube that is put in the kidney to drain urine directly from the kidney)out of 23 sampled residents. The facility census was 111 residents. A policy for nephrostomy care was requested and not received prior to exit. 1. Record review of Resident #2's Face Sheet showed he/she was admitted to the facility on [DATE] and had the following diagnoses: -Neuromuscular dysfunction of the bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems. -Paraplegia (paralysis of the legs and lower body, typically caused by a spinal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident with a percutaneous endoscopic gastrostomy tube (PEG tube - a tube that is placed into a patient's stomach as a means of feeding them when they are unable to eat) had orders for cares and monitoring of the PEG tube insertion site and to document the assessment and/or cleaning of the PEG insertion site for one sampled resident (Resident #24) out of 23 sampled residents. The facility census was 111 residents. Record review of facility policy entitled G-tubes dated 11/28/17 last revised 1/19/22 showed: -Infection could occur if aseptic (free from contamination caused by harmful bacteria, viruses, or other microorganisms) practices were not followed. -The G-tube might become dislodged from the stomach or the skin might become irritated at the site of insertion. -Once daily, the peristomal skin would be cleaned with mild soap and water (or solution listed specific per Physicians order) and allowed the skin to air-dry for 20…

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 monitor, assess, and follow physician's orders to provide adequate pain management for two sampled residents (Residents #108 and #21) out of 23 sampled residents. The facility census was 111 residents. Record review of the facility's Pain Management policy/procedure, revised 7/5/22 showed: -All residents who are receiving routine pain medication or PRN (pro re nata - as needed) pain medication on a frequent basis will have their pain evaluated and assessed prior to pain medication administration and within an hour after the medication was given to determine if the current pain medication regimen is effective to adequately manage the resident's acceptable pain level. -When dispensing any scheduled routine or PRN pain medication the Certified/Licensed/Registered Nursing staff administering the pain medication must determine the intensity of the pain. Pain should be rated on a 0 to 10 scale with 0 being no pain and 10 being the worst pain imaginable. If…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one sampled resident (Resident #21) who received dialysis services (a process of purifying the blood of a person whose kidneys are not working normally) communication between the facility and the dialysis center was documented and to ensure the dialysis catheter (an access point, meaning an entrance and exit point, for the blood during dialysis treatment) was monitored out of 23 sampled residents. The facility census was 111 residents. Record review of the facility's dialysis policy revised 3/18/23 showed: -The facility shall monitor a resident on dialysis using professional standards including: --On-going assessments and oversight before and after dialysis treatment. --On-going communication and collaboration with the dialysis facility. --The staff were to assess the dialysis access sight (dialysis catheter) for signs and symptoms of bleeding and/or infection. 1. Record review of Resident #21's admission Record showed he/she 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 interview and record review, the facility failed to submit a Third Party Liability (TPL) form (a form which is sent to Missouri (MO) Health Net, which gives an accounting of the remaining balance of that resident's funds in the resident trust account), which is required to be sent within 30 days after death, to MO Health Net after the death of one supplemental resident (Resident #1000), and failed to ensure the remainder of funds was sent to four discharged supplemental residents (Resident's #1001, #1002, #1003, and #111) after they were discharged to other facilities. The facility census was 109 residents. 1. Record review of Resident #1000's face sheet printed on [DATE] showed the resident died on [DATE] with a balance of funds of $16.00. Record review of the TPL form showed the form was mailed on [DATE], 61 days after the resident's death. During an interview on [DATE] at 1:25 P.M., the Business Office Manager (BOM) said he/she was new at that time and he/she was not aware of the number of days after…

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 two light fixtures in the 3rd floor south dining room illuminated during the lunch meal; to maintain the headboard of two beds in resident room [ROOM NUMBER] in good condition, and to maintain the shower chair in the 2nd floor south shower room in good condition. This practice potentially affected at least 14 residents using the 3rd floor south dining room and at least 20 residents who resided on 2nd floor south. The facility census was 109 residents. 1. Observations on 6/8/21 at 12:36 P.M., showed two light fixtures in the 3rd floor south dining room, were not illuminated during the lunch meal. Observation on 6/10/21 at 1:02 P.M., showed two light fixtures in the 3rd floor south dining room, were not illuminated in a time period just after the lunch meal. During an interview on 6/10/21 at 1:06 P.M., Licensed Practical Nurse (LPN) A said he/she had not noticed the lights in the dining room. During an interview on 6/10/21 at 1:08 P.M., the Director…

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 instructions of the recipe to maintain the temperature of ambrosia (a dessert made with tropical fruits, marshmallows, and at times, shredded coconut) at or below 41 degrees Fahrenheit (ºF ). This practice potentially affected at least 21 residents who ate the lunch meal in the 3rd floor South Dining room. The facility census was 109 residents. Record review of the 2021 recipe for ambrosia showed the following directions: -Chill all ingredients before preparation Maintain at 41 ºF or below. -Toss diced fruit with pineapple until bananas are coated with juice. -Drain thoroughly, add canned mandarin oranges and marshmallows. -Fold in whipped topping and sour cream. Chill overnight. Cover, label and date. -Keep chilled and maintain at a temperature of 41 ºF or below. 1. Observation of the preparation of ambrosia on 6/8/21 from 11:39 A.M. through 11:49 A.M., showed: -Two cans of mixed tropical fruit were brought from the storage room that were not chilled. -Two packages of marshmallows were brought from…

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

Based on observation, interview and record review, the facility failed to maintain the window unit air conditioner outflow vent free of a heavy dust buildup; to maintain the upper nozzle of the dishwasher spray wand free of debris inside the nozzles; to maintain 10 cutting boards in an easily cleanable condition and without numerous grooves; to install a light fixture at the area where the coffee was prepared; and to maintain the coffee filter holder in good repair. This practice potentially affected at least 100 residents who ate food from the kitchen. The facility census was 109 residents. 1. Observations on 6/8/21 from 9:09 A.M. through 1:15 P.M. showed: - A heavy buildup of dust on the window air conditioner unit. - The absence of a light fixture over the area where the coffee was made and the sliced bread was toasted. - The presence of debris inside the nozzles of the upper spray wand of the dishwasher. - A damaged coffee filter with a melted area that caused the coffee to go in a different directions in addition to the coffee pot under the filter. - 10 cutting boards that were…

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

Based on observation, interview and record review, the facility failed to ensure the trash container located at the food preparation area, had a lid on it when it was not being used and to ensure the outdoor dumpster was closed on 6/8/21, 6/9/21, 6/10/21, and 6/11/21. The facility census was 109 residents. 1. Observations on 6/8/21 showed the following: - From 8:33 A.M., through 9:00 A.M., the trash container at the food preparation area, was uncovered. - At 9:08 A.M., Dietary [NAME] (DC) A dumped a wax paper in the trash container; no cover was placed on the trash container. - At 9:12 A.M. Dietary Aide (DA) A dumped food into trash container; no cover was placed on the trash container. - At 9:22 A.M. DC A dumped gloves and plastic bag into trash container; no cover was placed on the trash container. - At 9:28 A.M., DA A dumped the remnant of hot cereal into trash container; no cover was placed on the trash container. - At 9:48 A.M., DC A dumped gloves into the open trash container; no cover was placed on the trash container. -At 10:12 A.M., DC A dumped the remnant of pureed food…

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 ceiling over the three compartment sink area in the kitchen without leaks; to maintain a metal bar which held a section of tile in place in the 3rd floor south dining without a sharp, jagged edge; to maintain the area under the ice machine in the 3rd floor Main Dining Room kitchenette free of debris; to maintain the area under the vending machines close to the elevators free of debris; to maintain the cabinet in the clean utility room free from a leaky drainage pipe; and to ensure that water from a leaky water pump in the boiler room was drained properly. The facility census was 109 residents. 1. Observation on 6/8/21 at 9:09 A.M., showed a leak from the ceiling over the three compartment sink in the kitchen. During an interview on 6/9/21 at 1:52 P.M., the Maintenance Director said the leak came from upstairs because the ice machine on the 3rd floor, is located over that area of the ceiling. 2. Observation of the 3rd floor South Dining room on 6/8/21 at 12:02 P.M. showed: - A 5.5 inch (in.) gap in the metal…

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 take necessary measures to prevent the presence of roaches in the kitchen, the 3rd floor south dining room and a housekeeping closet; to prevent the occurrence of gnats in the kitchen and in the 2nd floor South Clean Utility room; and to prevent the presence of mouse droppings in several resident rooms and offices. This practice potentially affected at least 40 residents. The facility census was 109 residents. 1. Observations on 6/8/21, showed: - At 8:46 A.M. many gnats flew around within the dishwashing room. - At 9:16 A.M., gnats flew around within the hot water heater section of the dishwashing room. During an interview on 6/8/21 at 1:43 P.M., the Dietary Manager (DM) said the gnats were horrible. 2. Observation with the Director of Nursing (DON) while he/she served the lunch meal on 6/8/21 at 12:28 P.M., showed one live roach which crawled on the wall adjacent to the steam table in the 3rd floor south dining room. 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 maintain the resident's dignity by failing to provide privacy during cares for one sampled resident (Resident #100) and to ensure the Foley catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid, that drains into a collection bag) bag was kept covered for two sampled residents (Resident #100 and #1) out of 25 sampled residents. The facility census was 109 residents. Record review of the facility's catheter care policy dated 2/26/21 showed catheter bags are to be placed in privacy bags to promote the resident's dignity. 1. Record review of Resident #100's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Paraplegia (loss of movement of both legs and generally the lower trunk) and quadriplegia (paralysis of all four extremities and usually the trunk). -Chronic kidney disease, stage 3. -Myelopathy (an injury to the spinal cord…

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 in writing the facility's bed-hold policy to the resident and/or the resident's representative prior to transfer/discharge for one sampled resident (Resident #69) out of 25 sampled residents. The facility census was 109 residents. Record review of the facility's Resident Transfer/Discharge, Immediate Discharge, and Therapeutic Leave Policy revised 4/29/21 showed: -Notice of Bed Hold Policy: --When a resident is transferred to the hospital or other location or when the resident goes on therapeutic leave, the facility must provide to the resident or their legal representative a written copy of the bed hold policy. --This notice must be given at the time of transfer or therapeutic leave. For emergency transfers, the notice must be given within 24 hours of transfer. --If the emergency transfer was to a hospital, the facility may send of a copy of the bed hold policy to the resident in the hospital if a hospital representative such as a social worker agrees and will confirm the resident received the copy in an email…

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 complete a baseline care plan reflective of the resident's immediate health and safety needs for one sampled resident (Resident #109) out of 25 sampled residents. The facility census was 109 residents. Record review of the Centers for Medicare and Medicaid Services (CMS) 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) User's Manual dated October 2019 showed: -Federal statute and regulations require nursing homes to conduct initial and periodic assessments for all their residents. -The resident enters the nursing home with a set of physician-based treatment orders. Nursing home staff should review these orders and begin to assess the resident and to identify potential care issues/ problems. -Within 48 hours of admission, the facility must develop and implement a Baseline Care Plan for the resident that includes the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a thorough discharge summary was completed to include documentation showing the recapitulation of the resident's stay at the facility, the resident's health status at discharge, and what supportive care/services he/she would need at the receiving continuing care facility. The facility also failed to ensure documentation of the disposition of the resident's medications (reconciliation) and the disposition of the resident's belongings upon discharge for one closed record resident (Resident #111) out of three sampled closed record residents. The facility census was 109 residents. Record review of the facility's Resident Transfer/Discharge, Immediate Discharge, and Therapeutic Leave Policy revised 4/29/21 showed: -When a resident is discharged or transferred the Interdisciplinary Discharge Summary (recapitulation) must be completed. -When the facility transfers or discharges a resident to another care facility or provider, the following information…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to thoroughly investigate and document a fall and follow the facility policy for one sampled resident (Resident #16) out of 25 sampled residents. The facility census was 109 residents. Record review of the facility's Post Fall Protocol policy revised 2/26/21 showed: -The purpose of the policy is to ensure that all residents who had a fall had accurate assessment and follow through to prevent further injury and recurrence of falls. -A fall is defined as any event, not purposeful and not from external force, which results in a resident coming in contact with the next lower surface. -Procedure: --The Licensed Practical Nurse (LPN)/Registered Nurse (RN) on duty will perform a full head to toe assessment of the affected resident immediately when informed of a fall. --Immediate vital signs are to be taken and include: ---Temperature. ---Respirations. ---Pulse. ---Blood pressure. ---Oxygen saturation (a measurement of how much oxygen the blood carries in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to keep a urinary catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid, that drains into a collection bag) bag below the level of the bladder (causing urine to flow back into the bladder which has the potential for infections) during mechanical lift (device used to lift and move a resident from one surface to another surface) transfers for two sampled residents (Resident #38 and Resident #100) out of 25 sampled residents. The facility census was 109 residents. Record review of the facility's catheter care policy dated on 2/26/21 showed: -The facility will ensure any resident with a urinary catheter will be maintained to prevent infection. -Catheter care procedures are as follows: --Make sure that urine is flowing out of the catheter into the drainage bag. --Keep the urinary drainage bag below the level of the bladder to prevent backflow of the urine. 1. Record review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that pain was managed for one sampled resident (Resident #67) and to ensure appropriate documentation related to the resident's pain on the Medication Administration Record (MAR) and in Nurse's Notes out of 25 sampled residents. The facility census was 109 residents. Record review of the facility's Medication Administration and Monitoring policy revised 2/26/21 showed medications were to be given according to physician's orders. 1. Record review of Resident #67's Face Sheet showed he/she: -admitted to the facility on [DATE]. -Was his/her own responsible party. -Had diagnoses which included: --Schizophrenia (a serious mental disorder in which people interpret reality abnormally, often leading to decreased independence in daily functioning). --Bipolar Disorder (mood disorders characterized usually by alternating episodes of depression and mania). --Insomnia (trouble falling and/or staying asleep). --Dental caries (permanently damaged areas in…

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 physician responded to the pharmacist's recommendation for a gradual dose reduction of psychotropic medications (also known as neuroleptics, are a class of psychotropic medication primarily used to manage psychosis (including delusions, hallucinations, paranoia or disordered thought), principally in schizophrenia but also in a range of other psychotic disorders. They are also the mainstay together with mood stabilizers in the treatment of bipolar disorder) for one sampled resident (Resident #90) out of 25 sampled residents. The facility census was 109 residents. Record review of the facility's monthly drug regimen review policy dated 2/26/21 showed: -The consultant pharmacist or his agent will review the drug regimen of each resident at least monthly and report, in writing any irregularities. -The consultant pharmacist will review the resident's clinical record, including the Physician orders sheets. -The consultant pharmacist…

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.