Hilltop At Blue River, The

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to serve the physician ordered texture and portion size to one sampled resident (Resident #22) with swallowing difficulties and who was at risk for weight loss out of 29 sampled residents. The facility census was 140 residents. Review of the facility's Therapeutic Diet policy and procedure dated 12/2020, showed: -The purpose was to ensure that the facility provided therapeutic diets to residents that meet nutritional guidelines and physician orders. -Therapeutic diets would not be given without a physician's order. -The therapeutic diet would be reflected on the resident's diet tray card. -The Nutrition Services Manager was responsible for ensuring each food item was pureed and served separately for a pureed diet per the menu and recipe and food portions are equal to the written portion sizes. -The Nutrition Services Manager would periodically review the resident's tray card and the physician's nutrition orders to ensure the information is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a nebulizer (a machine that turns liquid medicine into a mist that could have been easily inhaled) was available for respiratory treatments for one sampled resident, (Resident #10); failed to ensure the Continuous Positive Airway Pressure (CPAP a machine that delivers enough air pressure to a mask to keep the upper airway passages open during sleep) mask was correctly placed for one sampled resident, (Resident # 126) and failed to ensure oxygen equipment was stored in a sanitary manner for two sampled residents, (Resident #68 and Resident #126) out of 29 sampled residents. The facility census was 140 residents. Review of the facility's policy, Oxygen Administration, dated 6/2020 showed: -A physician's order was required to intiate oxygen therapy. -All oxygen tubing, humidifiers (a container for distilled water), masks, and cannulas (oxygen tubing) used to deliver oxygen would have been changed weekly and when visibly soiled.…

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 # 12) had received dental care out of 29 sampled residents. The facility census was 140 residents. Review of the facility's undated policy, Dental Services, showed: -All residents would receive appropriate oral cares if applicable on a daily basis. -It was the responsibility of each staff member within the nursing department to have ensured good oral care for each resident. -Assessment of the oral cavity and teeth was to have been performed upon admission and as necessary. -Observe mouth for any adverse conditions such as bleeding, swelling, unusual mouth odor or any complaint of pain or discomfort. -Note any such condition in the resident's chart and report the problem to the charge nurse. -Refer and or assist residents to obtain dental services as indicated for routine and emergency dental care including making appointment for the resident, if needed or requested and arranging transportation to and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure Enhanced Barrier Precautions (EBP-an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) by expanding the use of gowns and gloves during high-contact resident care activities) were implemented for one sampled resident (Resident #82) with a foot wound and receiving intravenous (IV-a way of giving a drug or other substance through a needle or tube inserted into a vein) antibiotic therapy; and out of 29 sampled residents. The facility census was 140 residents. Review of the facility's Standard and Enhanced Precautions policy and procedure dated 4/1/24, showed the purpose was to ensure the use of appropriate personal protective equipment (PPE-protective clothing, helmets, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection) to improve infection control as required in the care of residents. The policy showed: -Enhanced barrier…

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 obtain a physician order for self-administration of medication at bedside and failed to evaluate and document the ability to self-administer medication for one sample resident (Resident #3) out of 12 sampled residents. The facility census was 137 residents. Review of the facility's policy titled Resident Self-Admin Meds Clinically Appropriate dated August 2020 showed: -If a resident desired to self-administer medications, an assessment was conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out the responsibility during the care planning process. -For residents who self-administer, the interdisciplinary team verified the resident's ability to self-administer medications by means of skill assessment conducted on a monthly basis or when there was a significant change in condition. -The results of the interdisciplinary team assessment of resident skills and of the determination regarding…

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 Transportation Driver (TD) A followed protocol related to safely securing a resident's wheelchair according to facility policy and training, affecting one sampled resident (Resident #3), who fell backwards in his/her wheelchair during transport, out of seven sampled residents. The facility census was 134 residents. On 11/8/24, the Administrator was notified of the past noncompliance which took place on 10/18/24. TD A reported the accident to his/her supervisor who provided immediate training. Drivers received documented education on 10/21/24 related to wheelchair safety during transport. The facility did an investigation and found TD A did not follow facility policy, protocols, and training related to securing the resident's wheelchair and the employee was disciplined. The deficiency was corrected on 10/21/24. Review of the facility's Vehicle Safety Program, undated showed the Administrator was responsible for ensuring the training 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 controlled substances (is generally a drug or chemical whose manufacture, possession and use is regulated by a government, such as illicitly used drugs or prescription medications that are designated by law) were counted during change of shift or when keys were transferred to another responsible party resulting in a total of 60 tablets Oxycodone Immediate Release (a narcotic pain medication) 30 milligram (mg) that were not accounted for for one sampled resident (Resident #3) out of the three sampled residents. The facility census was 126 residents. On 9/20/23, the Administrator was notified of the past noncompliance which took place on 9/1/23. Licensed Practical Nurse (LPN) reported unaccounted for controlled substances to Human Resources (HR) on 9/1/23. HR then informed the Director of Nursing (DON). DON and the Administrator completed a full in house audit of controlled substances on 9/1/23. Education related to controlled substances count 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.

Based on observation, interview, and record review, the facility's dietary staff failed to sanitize their work areas before, during and after preparing food; to take food temperatures at the foods' heat source; to sanitize the juice and beverage apparatuses nozzle; and to wear the appropriate hair restraints while in the kitchen. The facility census was 125 residents. 1. Observations on 7/17/23 between 5:03 A.M. and 7:55 A.M. in the kitchen showed: -At 5:05 A.M. the beverage/juice gun was not disassembled, soaking in a sanitizing solution mixture. -The beverage/juice gun's nozzle appeared to have various beverage and juice sediment stuck to the inside and out and, was actually sticky to the touch. -The Dietary [NAME] (DC) had a full beard with sideburns and a mustache, and did not have his/her entire facial hair covered. -At 5:10 A.M. the DC prepared sausage patties on the food prep table without sanitizing it first. -After the DC prepared and placed the trays of sausage patties in the oven, he/she proceeded prepare the hot cereal on the same food preparation table in the same area.…

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 lids of the dumpster's were closed for two days during the survey. The facility census was 125 residents. 1. Observations on 7/17/23 at 8:33 A.M., 9:30 A.M. and on 7/19/23 at 9:37 A.M., and 1:06 P.M., showed: -The facility had two dumpster's for trash, each with two lids attached to them. -One lid on each dumpster was open. -On 7/19/23 at 1:06 P.M. two employees placed trash bags into the dumpster and did not close the lid. During an interview on 7/21/23 at 10:33 A.M., the Assistant Dietary Manager said : -Each and every individual person that uses the dumpster is responsible for closing the lids after they use the dumpster to discard trash. -There are several people and facility departments that use the dumpster's for trash. -Will speak with the Administrator about in-servicing all of the departments regarding the use of the dumpster and their lids. During an interview on 7/21/23 at 11:33 A.M., the Administrator said that all of the departments use the dumpster's for trash and would in-service 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.

Based on observation, interview and record review, the facility failed to complete a Facility Assessment to determine resources necessary to meet the needs of the residents, such as assessment of the resident population, staff competencies needed to provide resident care, physical plant requirements, services needed, technology resources and facility and community based risk assessment. A total of 27 residents were sampled. The facility census was 125 residents. Facility Assessment policy was requested and not received by day of exit 7/21/23. Review of the facility's Resident Census and Condition dated 7/17/23 showed the following resident demographics in the building: -Six residents with indwelling catheters (a tube with retaining balloon passed through the urethra into the bladder to drain urine). -85 residents were frequently incontinent. -Six residents had an intellectual disability (when a person has certain limitations in cognitive functioning and skills, including conceptual, social and practical skills, such as language, social and self-care skills) and/or developmental…

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 staff treated one sampled resident (Resident #102) with dignity when two staff members used disrespectful profanity towards the resident and around other residents out of 27 sampled residents. The facility census was 125 residents. Review of facility policy Resident Rights revised 8/2020 showed: -All residents have the right to a dignified existence. 1. Review of Resident #102's Face Sheet showed an admission to the facility on 3/19/22 with diagnoses of: -Dementia (a progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change). -Cognitive communication deficit. -Schizoaffective Disorder (a combination of symptoms often followed by periods of improvement, symptoms may include delusions, hallucinations depressed episodes and manic periods of high energy). -Anxiety Disorder. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure six sampled residents (Resident #52, #119, #50, #41, #15, #47) were offered the right to formulate and/or obtain existing advanced directives (legal documents that provide instructions for medical care and only go into effect if you cannot communicate your own wishes) out of 27 sampled residents. The facility census was 125 residents. Review of the facility's policy Advanced Directives revised 8/2020, showed: -At the time of admission, admission Staff or designee would inquire about the existence of an Advanced Directive. -If no Advanced Directive exists, the Facility provided the resident with the opportunity to complete the Advance Directive upon resident request. -Assistance was provided as necessary to execute an Advance Directive. -A copy of the Advance Directive was maintained as part of the resident's medical record. -If the resident had an Advance Directive, admission staff or designee would place a copy of the Advance Directive in the…

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

Based on interview and record review, the facility failed to ensure the Employee Disqualification List (EDL - a listing of individuals who have been determined to have abused or neglected a resident), Criminal Background Checks (CBC) and Nurse Aide (NA) Registry checks were completed to ensure potential employees did not have a Federal Indicator (FI - a marker given to a potential employee who has committed abuse, neglect, or misappropriation of property against residents) in accordance with the state and federal regulation prior to hire on ten out of ten employees sampled. The facility census was 125 residents. Review of the Missouri Revised Statute Chapter 660, Section 660.317 showed, prior to allowing any person who has been hired as a full time part time or temporary position to have contact with any patient or resident, the provider shall, or in the case of temporary employees hired through or contracted for an employment agency, the employment agency shall prior to sending a temporary employee to a provider: -Request a criminal background check as provided in section 43.540,…

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 four sampled residents (Residents #6, #12, #104, and #120), who were dependent upon staff for activity participation, had opportunities for activities of personal interest on a daily basis out of 27 sampled residents. The facility census was 125 residents. Review of the facility's Activities Program policy and procedure, dated 6/2020 showed: -Residents will be encouraged to participate in activities to make life more meaningful, to stimulate and support physical and mental capabilities to the fullest extent, and to enable the resident to maintain the highest attainable social, physical and emotional functioning. -A variety of activities should be offered on a daily basis, including weekends and evenings. -Activities are developed for individual, small group and large group participation. -The activity schedule is posted in large print in a location accessible to residents, their families and staff. -The Director of Activities or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of Resident #5's admission Record showed: -He/she was admitted to the facility on [DATE]. -He/she had diagnoses of hallucinations (hearing, seeing, feeling, smelling, or tasting things that are not real), psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with external reality), and paranoid schizophrenia (a serious mental illness that interferes with a person's ability to think clearly, manage emotions, make decisions and relate to others and in which a person has an extreme fear and distrust of others). Review of the resident's Pharmacy Note dated 5/20/22 showed please ensure target behavior and side effect monitoring are in place in order to evaluate the continued appropriateness of the resident's antipsychotic medication - Clozapine (antipsychotic medication) . Review of the resident's Pharmacy Note dated 7/19/22 showed please ensure target behavior and side effect monitoring are in place in order to evaluate the continued appropriateness 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 interview and record review, the facility failed to ensure three sampled residents (Resident #10, #119, and #120) signed arbitration agreements (a private process where disputing parties agree that one or several individuals can make decisions about the dispute after receiving evidence and hearing arguments) after this was explained in a manner they understood and the resident had the right to communicate with state officials out of three sampled residents out of three sampled residents for arbitration. The census was 125 residents. Record review of the facility Arbitration Agreement policy revised 10/24/22 showed: -To provide a lawful opportunity for a provider of health services and residents/responsible parties to enter into an enforceable written contract to settle a dispute outside the court through and arbitration process. -The healthcare arbitration agreement should comply with federal and state laws. -The person tasked with obtaining signatures for arbitration agreements need to clearly explain…

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 three sampled residents (Resident #10, #119, and #120) signed arbitration agreements (a private process where disputing parties agree that one or several individuals can make decisions about the dispute after receiving evidence and hearing arguments) that contained the selection of a neutral arbitrator would be agreed upon by both parties (resident and facility) out of three sampled residents for arbitration. The census was 125 residents. Record review of the facility Arbitration Agreement policy revised 10/24/22 showed: -To provide a lawful opportunity for a provider of health services and residents/responsible parties to enter into an enforceable written contract to settle a dispute outside the court through and arbitration process. -The healthcare arbitration agreement should comply with federal and state laws. 1. Review of Resident #10's admission Minimum Data Set (a federally mandated assessment tool required to be completed by facility…

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

Based on interview and record review, the facility failed to implement an effective quality assurance (QA)/quality assurance performance improvement (QAPI) program when they failed to ensure they implemented appropriate interventions to correct on-going, systemic issues regarding weights not being completed or correctly completed and fall interventions not being implemented; and to complete effective audits for weights and falls after issues were determined in QA. The facility census was 125 residents. Review of the facility's policy QAPI Program, revised 10/24/2022, showed: -The facility implemented and maintained an ongoing, facility-wide QAPI program designed to monitor and evaluate the quality of resident care, pursue methods to improve care quality, and resolved identified problems. -Provided a means to identify and resolve present and potential negative outcomes related to resident care and safety. -Established and implemented plan to correct deficiencies and monitored the effects of action plans on resident outcomes. -The Quality Assessment and Assurance (QAA) committee…

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

Based on interview and record review, the facility failed to maintain an effective infection control program that included tracking and trending of facility resident infections. The facility census was 125 residents. Review of the facility Infection Prevention and Control Program, revised October 24, 2022 showed: -The facility must establish an Infection Prevention and Control Program under which it identifies, investigates, controls, and prevents infections in the facility and maintains a record of incidents and corrective actions related to infections. -The Infection Preventionist (IP) collects, analyzes, and provides infection data and trends to nursing staff, physicians. -The IP will determine specific sites and pathogen trends. -The IP will at least on a monthly basis conduct an infection control audit to identify trends. -Infection data is analyze to identify trends. -Infection rates are compared to previous months in the current year and to the same month in previous years to identify trends, patterns, or problems that reflect the development of healthcare-associated…

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 they completed an antibiotic stewardship program over the past 12 months. The facility census was 125 residents. Review of the facility Antibiotic Stewardship Program revised June 2020 showed: -The Antibiotic Stewardship Program (ASP) was designed to promote appropriate use of antibiotics while optimizing the treatment of infections, and reduce the possible adverse events associated with antibiotic use. -The infection control committee (ICC) would review and monitor antibiotic usage patterns on a regular basis and would obtain and review results from microbial cultures, resistant organisms, alerts and antibiograms (reports that show how susceptible subtypes of disease causing organisms are to a variety of antibiotics) tables showing how susceptible a series of organisms are to different antimicrobials) from the lab for trends of antibiotic resistance. -The IP would report on the number of antibiotics prescribed (days of therapy) and the number of residents treated each month and would collect and analyze 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 two sampled residents (Resident #47 and #104) received teaching regarding the benefits and risks of influenza and pneumococcal vaccination, and that the resident's consent/declination was retained in the resident's medical record for two of five residents selected for review for vaccination. The facility census was 125 residents. Policies were requested for resident influenza and pneumococcal vaccination were requested and not received. 1. Review of Resident #47's electronic medical record (EMR) dated 8/23/22 through 7/21/23 showed: -His/her Immunization Report showed that he/she had refused the pneumococcal and influenza vaccines with no documented dates of his/her refusal refusals. -No documentation regarding teaching regarding the benefits and risks of influenza and pneumococcal vaccination. -No documentation that the resident had refused/consented the influenza and pneumococcal vaccines. Review of the resident's quarterly Minimum Data Set…

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 residents and/or family/representative of care plan (written out plan for the care of the resident) meetings or have care plan meetings for one sampled resident (Resident #52) out of 26 sampled residents. The facility census was 125 residents. Review of the facility's policy titled Care Planning Nursing Manual-Nursing Administration dated 6/2020 showed: -The facility would invite the resident, if capable, and the resident's family to care plan meetings and used its best efforts to have scheduled care planning meetings at times that are were convenient for the resident and family. -When a resident did not have family, or if the resident/family requested it, the Interdisciplinary team (IDT) would invite the Ombudsman to attend the care planning meeting. 1. Review of Resident #52's admission Record showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Diabetes Mellitus (a chronic condition that affects the way the body…

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 notify the physician when behaviors became excessive for one sampled resident (Resident #15) out of 27 sampled residents. The facility census was 125 residents. Review of the facility Change of Condition policy updated 6/2020 showed: -The nurses were responsible for notifying the residents' physician of a significant change including a deterioration in mental health. -The physician should be notified timely with a change of condition. 1. Review of Resident #15's admission Record showed he/she had the following diagnoses: -Anxiety (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus). -Depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living). -Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor,…

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 ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) of a resident discharge from the facility for one sampled resident (Resident #41) and two closed sampled residents (Resident's #126 and #129) and to ensure that written notice of transfer or discharge was provided to the resident and/or family for one sampled resident (Resident#41) and for one closed sampled resident (Resident #126) out of three closed record sampled residents. The facility census was 125 residents. Review of the facility policy and procedure Transfer and Discharge, revised 8/2020 showed: -To ensure that residents are transferred and discharged from the facility in compliance with state and federal laws and to provide a complete, safe, and appropriate discharge planning and necessary information to the continuing care provider. -Documentation relating to resident's transfer/discharge will be maintained…

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 the facility's bed-hold policy before transferring or discharging the resident to the hospital for one sampled resident (Resident #41) out of 33 sampled residents. The facility census was 125 residents. Record review of the facility's Bed Hold policy revised 6/2020 showed the facility would notify the resident or his/her representative in writing of the bed hold policy any time a resident was transferred to an acute care hospital. 1. Review of Resident #41's discharge MDS dated [DATE] showed the resident was sent to the hospital return anticipated. Review of the resident's Nurses Notes dated 5/1/23 showed: -The resident was found unresponsive. -The resident's physician was notified. -The resident was sent to the hospital. -There was not documentation showing a bed hold policy was provided. Review of the resident's electronic medical record on 7/20/23 showed no documentation of the bed hold…

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 include one sampled resident's (Resident #5) 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) in his/her comprehensive care plan out of 27 sampled residents. The facility census was 125 residents. Review of the facility's Care Planning policy revised June 2020 showed: -The facility would develop a comprehensive person-centered care plan for each resident. -The care plan would include measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs. -Each resident's comprehensive care plan would describe the services that would be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being, and specialized services including rehabilitative…

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 perform restorative nursing services, and to apply a therapeutic splint for one sampled resident (Resident #52) out of 27 sampled residents. The facility census was 125 residents. Review of the facility's policy titled Restorative Nursing Program Guidelines dated 6/2020 showed: -A resident would be started on a Restorative Nursing program when a resident was discharged from formulized physical, occupational, or speech rehabilitation therapy. -General restorative nursing care was that which did not require the use of a qualified professional therapist to render such care. -Basic restorative nursing categories include: --Active range of motion. --Passive range of motion. --Splinting or bracing. --Dressing or grooming. 1. Review of Resident #52's admission Record showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Diabetes Mellitus (a chronic condition that affects the way the body processes blood sugar).…

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 coordination of care between the facility and the dialysis (a process for removing waste and excess water from the blood, and is primarily used to provide an artificial replacement for lost kidney function in people with renal failure) center was maintained to ensure the continuum of care for one sampled resident (Resident #47) out of 27 sampled residents. The facility census was 125 residents. Review of the facility's Dialysis Care undated policy showed: -The facility would communicate and collaborate in writing with the dialysis clinic. -This should include any medication changes, changes of condition and tolerance of the resident's procedure. 1. Review of Resident #47's admission Record showed the resident had the following diagnoses: -End stage renal disease (the gradual loss of kidney function). -Dependent on dialysis. Review of the resident's Care Plan revised 1/12/23 showed: -The resident received dialysis services on Monday, Wednesday and Friday. -There was no documentation in the care plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide necessary behavioral health care services for a resident's psychosocial well-being when staff did not address the resident's behaviors, monitor behaviors, and intervene when behaviors became excessive for one sampled resident (Resident #15) out of 27 sampled residents. The facility census was 125 residents. Review of the facility Behavior Management policy revised 6/2020 showed: -The purpose of the policy was to implement the most desirable and effective interventions to change, modify decrease, or eliminate behaviors that were distressing to the resident. -The staff were to identify residents with behaviors that may pose a risk to self or others. -Develop individual and practical care strategies based on assessed needs. -Implement a behavior management program. -Complete on-going assessments, monitoring, and evaluation of the effectiveness of medications. -The goal was to improve the residents' quality of life. -As part 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 ensure staff consistently and accurately documented resident behaviors and/or monitored the effectiveness of interventions for two sampled residents (Residents #120 and #6) out of 27 sampled residents. The facility census was 125 residents. Review of the facility Behavior Management policy revised 6/2020 showed: -The purpose of the policy was to implement the most desirable and effective interventions to change, modify decrease, or eliminate behaviors that were distressing to the resident. -The staff were to identify residents with behaviors that may pose a risk to self or others. -Develop individual and practical care strategies based on assessed needs. -Implement a behavior management program. -Complete on-going assessments, monitoring, and evaluation of the effectiveness of medications. -The goal was to improve the residents' quality of life. -As part of the behavior management process staff would provide ongoing assessment, monitoring…

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 medically related social services to attain the highest practical physical, mental and psychosocial well-being of one resident by not providing supportive services for one sampled resident (Resident #15) who exhibited changes in behaviors, such as excessively stacking belongings all over his/her room and bed, using Rubber Maid totes and a plunger to wash clothing, believing he/she had gone blind for a few days, and sweeping up mice droppings daily which were not present in the room. In addition, the facility failed to monitor and provide practical care strategies based on assessment needs out of 27 sampled residents. The facility census was 125 residents. Review of the facility Social Services policy revised 08/2020 showed: -Medically related social services were provided to residents in order to maintain and improve the residents' well-being. -The resident was assessed for factors that may have a negative impact on his/her life.…

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's (Resident #5) drug regimen was free from antipsychotic (a type of medication used treat a severe mental condition in which thought and emotions are so affected that contact is lost with external reality) medication without adequate indications for use as demonstrated by identification of and monitoring of target behaviors, and by monitoring for adverse reactions for use and without monitoring for adverse effects, out of 27 sampled residents. The facility census was 125 residents. A policy for antipsychotic medications was requested and not received. 1. Review of Resident #5's admission Record showed: -He/she was admitted to the facility on [DATE]. -He/she had diagnoses of hallucinations (hearing, seeing, feeling, smelling, or tasting things that are not real), psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with external reality), and paranoid schizophrenia (a serious…

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 medication error rate of less than 5 percent (%). Out of 34 observed medication opportunities, two errors occurred resulting in an error rate of 5.88%. One error involved an eye drop medication (Resident #16), one error involved an inhaler medication (Resident #33). The facility census was 125 residents. Review of facility policy and procedure for Eye Drop Administration, revised 8/2020 showed: -Put on examination gloves. -Remove the cap, taking care to avoid touching the dropper tip. Place the cap on the barrier or a clean, dry surface. -Tilt the resident's head back slightly. -With a gloved finger, gently pull down the lower eyelid to form a pouch while instructing the resident to look up. Place your other hand against the resident's forehead to steady. Hold the inverted medication bottle between the thumb and index finger and press gently to instill the prescribed number of drops into the pouch near the outer corner 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 provide residents with activities to meet the interests and abilities of four sampled residents (Residents #4, #18, #62, and #153) out of four residents sampled for activities. There were 21 residents sampled overall. The facility census was 105 residents. Record review of the facility's Activities Program policy dated June 2020 showed: -Instructions to encourage residents to participate in activities to make life more meaningful, to stimulate and support physical and mental capabilities to the fullest extent and to enable the resident to maintain the highest attainable social, physical and emotional functioning. -Provide an activity program to meet the needs, interests and preferences of the residents. -Complete an initial activity assessment within seven days of admission. -Complete the activity preference section of the Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff and used for care planning)…

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 label medications with dates when they were first opened; failed to maintain cleanliness of medication bottles; failed to remove a medication that was discontinued from the medication cart, and dispose of it appropriately; and failed to ensure the medication refrigerator was maintained and clean. The facility census was 105 residents. Record review of facilities undated Medication Storage policy showed: -Medication storage areas are kept clean, well-lit, and free of clutter and extreme temperature and humidity. -Certain medications or package types, such as intravenous (IV) solutions, multiple dose injectable vials, ophthalmics (relating to the eye and its diseases), nitroglycerin tablets (medication used to prevent chest pain (angina) in people with a certain heart condition (coronary artery disease)), once opened, require an expiration date shorter than the manufacture's expiration date to insure medication purity and potency. Once any medication or biological package is opened, the facility should follow…

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 obtain consent prior to the administration of the coronavirus disease 2019 (COVID-19-a respiratory disease caused by a new coronavirus, named SARS-CoV-2 and the disease it causes has been named coronavirus disease 2019) vaccine from the resident's Durable Power of Attorney (DPOA- a person previously identified to make decisions for an individual in the event of inability to make wishes known) for one supplemental resident (Resident #11) out of seven residents sampled for vaccinations. The overall sample was 21 residents. The facility census was 105 residents. The facility did not have a policy regarding obtaining consent. 1. Record review of Resident #11's care plan initiated 2/5/20 showed the resident was cognitively impaired. Record review of the resident's DPOA activation letter dated 2/18/20 showed the resident was deemed incapable of making appropriate healthcare decisions by two physicians and the resident's DPOA was activated. Record review of the resident's notes in the electronic health record dated December 2020…

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.