Kingswood Senior Living

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure care plans were reviewed, updated and/or revised for two sampled residents (Residents #1 and #3) out of four sampled residents. The facility census was 67 residents. Review of the facility Care Plans, Comprehensive Person-Centered dated 03/2022 showed: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident physical, psychosocial and functional needs is developed and implemented for each resident. -The comprehensive, person-centered care plan: --Includes measurable objectives and timeframe's. --Describes the services that to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. --Reflects currently recognized standards of practice for problem areas and conditions. -Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. Review of the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure weekly skin/wound assessments, wound assessments included a detailed description and measurements of the pressure ulcer/injury (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), and to notify the resident's physician of a new pressure ulcer to obtain treatment orders in a timely manner for one sampled resident (Resident #1) out of four sampled residents. The facility census was 67 residents. Review of the facility Pressure Injury Risk assessment dated 3/2020 showed: -The risk assessment should be conducted as soon as possible after admission, but no later than eight hours after admission is completed. -Once the assessment is conducted and risk factors are identified and characterized, a resident-centered care plan can be created to address the modifiable risks for pressure injuries. -Repeat the risk assessment weekly…

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 Registered Dietitian (RD) was in the facility to perform dietary assessments and to consult with dietary staff in the kitchen. This practice affected two sampled residents (Residents #1 and #2) who needed dietary assessments during the time span when there was no RD coming to the facility out of four sampled residents. The facility census was 67 residents. Review of the facility Dietitian policy dated 11/2022 showed: -A qualified dietitian or other clinically qualified nutrition professional will help oversee food and nutrition services provided to the residents. -The dietitian or nutrition professional may be a full time or part time consultant or an employee depending on the current requirements of the facility. --The requirements are based on: ---Assessments and care plans of resident nutritional needs. ---The over all facility assessment of the number, acuity and diagnoses of the resident population. -Our facility's dietitian 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.

Based on observation and interview, the facility failed to maintain the ceiling tiles, light fixtures, and sprinkler heads, which were over the food preparation table and the dishwasher area, free of a dust buildup. This practice potentially affected all residents who ate food prepared in the kitchen. The facility census was 58 residents. 1. Observation on 9/25/23 at 9:42 A.M., showed a buildup of dust on the sprinkler head on the ceiling close to the food preparation area. Observation on 9/25/23 at 9:43 A.M., showed a dust buildup on the ceiling tiles and on the light fixtures over the food preparation table. Observation on 9/25/23 at 9:47 A.M., showed a buildup on the ceiling tiles and on the light fixtures over the dishwasher area. During an interview on 9/25/23 at 1:01 P.M., the Director of Dining Services said there was a utility person that cleaned the ceiling tiles and light fixtures every month. During an interview on 9/25/23 at 1:03 P.M. the Dietary Utility Person said he/she had not yet cleaned the ceiling tiles and light fixtures over the dishwasher area.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of Resident #44's Face Sheet showed he/she was admitted to the facility on [DATE], with diagnoses including shortness of breath, respiratory failure, chronic obstructive pulmonary disease (COPD- a chronic inflammatory lung disease that causes obstructed airflow from the lungs), heart failure, kidney disease, fluid overload and cellulitis (a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin). Review of the resident's annual MDS dated [DATE], showed the resident: -Was alert and oriented. -Needed extensive assistance with bathing and hygiene, limited assistance with dressing and toileting. -Needed supervision with ambulation and was able to mobilize in a wheelchair. -Had no skin problems or other wounds. -Received ointment treatments and application of dressings to his/her feet and other areas (other than feet). Observation on 9/25/23 at 9:45 A.M., showed the resident was sitting in his/her wheelchair with oxygen on. He/she had a wound on his/her…

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 do or maintain the beauty shop ceiling vent free from a dust buildup; to maintain the floor in the 1st floor east kitchenette free from a buildup of rust and water; maintain the restroom ceiling vent in resident room [ROOM NUMBER] free from a buildup of dust; to maintain resident rooms [ROOM NUMBERS] free from a buildup of cobwebs; to maintain the floor in the 2nd floor west kitchenette free from a a buildup of debris; failed to maintain hot water temperatures at or close to 105 ºF (degrees Fahrenheit) in resident rooms 123, 114, 212, 223 and 216 for two days of the survey. This practice potentially affected at least 35 residents who resided in or used those areas. The facility census was 58 residents. 1. Observation on 9/26/23 with the Director of Facility Operations showed: -At 1:55 P.M., there was a buildup of dust inside the ceiling vent in the beauty shop. -At 2:16 P.M., there was a buildup of water and rust behind the ice machine in the 1st floor…

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 document a comprehensive assessment for a suprapubic (S/P) catheter (a urinary bladder catheter inserted through the skin about one inch above the symphysis pubis) stoma (surgical opening) site weekly for two sampled residents (Resident #23 and #35); to document a suprapubic catheter change on 8/1/23 and on 9/1/23 for one sample resident (Resident #23); to ensure a dignity bag (a bag that the drainage bag is placed into to prevent contamination and other people seeing the urine) was placed for three sampled residents (Resident #19, #4, and #35); to complete physician's ordered cares to the catheter for three sampled residents (Resident #19, #4, and #35); to ensure the drainage bag was managed appropriately to prevent infection for two sampled residents (Resident #35 and #4); to ensure a comprehensive care plan included the type of catheter, location for one sampled resident (Resident #23); and to follow physician's orders 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 observation, interview, and record review, the facility failed to ensure respiratory equipment was properly stored for four sampled residents (Resident #44, #10, #35, and #20), and failed to care plan the use of respiratory equipment for three sampled residents (Resident #44, #35, and #20) out of 15 sampled residents. The facility census was 58 residents. Review of the facility's policy, titled Continuous Positive Airway Pressure (CPAP-a method of respiratory therapy in which air is pumped into the lungs through the nose or nose and mouth during spontaneous breathing)/Bilevel Positive Airway Pressure (BiPap-a type of device that helps with breathing) Support dated March 2015, showed: -Staff were to clean Cpap and BiPap masks with warm, soapy water for five minutes, rinse with warm water, and allow it to air dry. A copy of the facility's respiratory equipment storage policy was not received at time of exit. Review of the facility's policy, titled Goals and Objectives, Care Plans dated April 2009, showed:…

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 justification for re-implementing an elopement risk device (a bracelet that the resident wears that is used to keep track of resident and provides the facility an additional layer of security that allows sensors on doors to alarm when the resident attempts to exit) and to care plan the device for one sampled resident (Resident #46) out of 15 sampled residents. The facility census was 58 residents. Review of the facility's undated elopement risk device policy and procedure showed: -Wander guard placement was determined by resident assessment, history of wandering or getting lost or turned around. -Assessments should be done quarterly or as needed. -Residents were provided a bracelet by the facility. -Wander guard placement would be care planned. 1. Review of Resident #46's Face Sheet showed he/she was admitted on [DATE], with diagnoses including: -Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills…

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 the amount of $4,281.75 in the reconciliation (the process of verifying two sets of records to ensure consistency and accuracy) calculations which were completed in June 2023 for one discharged resident (Resident #500) and to obtain a resident signature or other evidence of the resident's approval for a check written for $375.00 for one sampled resident (Resident #2) account. This practice affected one discharged resident (Resident #500) and one sampled resident (Resident #2) out of two sampled residents who allowed the facility to hold funds. The facility census was 58 residents. 1. Review of Resident #500's discharge records showed he/she moved away from the facility on 1/10/23. Review of the resident's trust fund monthly statement showed a check dated 6/16/23, which was written for $4,281.75 to return the resident's money to Social Security. Review of the reconciliation worksheet dated 6/1/23 through 6/30/23, showed the $4,281.75, was not…

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

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 within 30 days of death, to Missouri Health Net for one deceased resident (Resident #501). The facility census was 58 residents. 1. Review of Resident #501's medical records showed the resident passed away on [DATE], which was 113 days prior to the resident fund review on [DATE]. During an interview on [DATE] at 11:23 the Director of Finance said: -The resident received Medicaid as a part of his/her funding for his/her stay at the facility. - A TPL form should have been filled out since the resident passed away.

Based on interview and record review, the facility failed to maintain a surety bond sufficient to ensure the protection of resident funds. The facility census was 58 residents. 1. Review of the facility maintained Resident Trust Reconciliation on 9/29/23, showed an average monthly balance of $ 7,894.03. During an interview on 9/26/23 at 10:42 A.M., the Director of Finance said the surety bond was updated two years ago and he/she would really have to look at the balances. Review of the facility's Surety Cancellation and Nonrenewal Notice on 10/19/23, showed the Notice was dated 7/1/23, received by the Department of Health & Senior Services on 8/3/23 and cancelled the surety bond effective 10/2/23, making the surety bond insuffiecient by $12,000.

Based on interview and record review, the facility failed to provide restorative therapy (therapy given to either reach a higher level or maintain a current level of functioning) services as ordered for one sampled resident (Resident #48) out of 15 sampled residents. The facility census was 58 residents. Review of the facility's policy, titled Restorative Nursing Services dated July 2017, showed: -Restorative therapy may or may not be accompanied by formal rehabilitation services such as Physical Therapy (PT-therapy that is used to preserve, enhance, or restore movement and physical function impaired by disease, injury, or disability), Occupational Therapy (OT-therapy that is used to promote independence in activities of daily living), and Speech Therapy (ST-therapeutic treatment of impairments related to communication and swallowing). 1. Review of Resident #48's face sheet showed he/she was admitted with a diagnosis of muscle wasting of his/her right and left lower leg. Review of the resident's PT Progress and Discharge Summary, signed 7/12/23, showed: -The Physical Therapist…

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 and document a comprehensive initial assessment of the resident's leg wounds and comprehensive ongoing assessments of the resident's leg wounds; to care plan the resident had cellulitis that was being treated; and to use proper skin issues and treatments for one sampled resident (Resident #44) out of 15 sampled residents. The facility census was 58 residents. 1. Review of Resident #44's Face Sheet showed he/she was admitted to the facility on [DATE], with diagnoses including shortness of breath, respiratory failure, chronic obstructive pulmonary disease (COPD- a chronic inflammatory lung disease that causes obstructed airflow from the lungs), heart failure, kidney disease, fluid overload and cellulitis (a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin). Review of the resident's Nursing Notes showed on 8/16/23, the resident's skin assessment was completed. The resident had…

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 assess a resident prior to and after dialysis (a mechanical way to filter the blood and remove waste when the kidneys stop functioning) for one sampled resident (Resident #20) out of 15 sampled residents. The facility census was 58 residents. Review of the facility's undated policy, titled Pre/Post dialysis Nursing Assessment showed: -Staff were to create and fill out the Dialysis Nursing Pre/Post Assessment, print it out, and send it with the resident to dialysis. -Staff were to retrieve the form when the resident returned from dialysis and place it in the communication book. 1. Review of Resident #20's face sheet showed he/she was admitted with the following diagnoses: -End Stage Renal Disease (the kidneys no longer work as they should to meet the body's needs). -Type 2 Diabetes Mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to obtain dental services, care plan dental problems, and accurately record dental problems on the Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) for one sampled resident (Resident #48) out of 15 sampled residents. The facility census was 58 residents. Review of the facility's undated policy titled Dental Services showed: -Staff were to ensure residents received routine and emergency dental services. -The Social Services Designee (SSD) was to assist residents with arranging appointments, transportation, and reimbursement of dental services, if eligible. -Staff were to record all dental services provided in the resident's medical record. Review of the facility's policy, titled Goals and Objectives, Care Plans dated April 2009, showed: -Staff were to enter goals and objectives on each resident's care plan so that all disciplines had access to such information and were able to report…

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 mechanical soft chicken was maintained at or close to a temperature of 120 ºF (degrees Fahrenheit) for one supplemental resident (Resident #9) on the steam table and at the time of service. This practice affected one resident. The facility census was 58 residents. 1. Review of Resident #9's face sheet showed diagnoses which included hemiplegia (paralysis on one side of the body), aphasia (having difficulty with their language or speech. It's usually caused by damage to the left side of the brain (for example, after a stroke), diabetes mellitus (when the body can't produce enough of a hormone called insulin, or the insulin it produces isn't effective in order to digest carbohydrates), generalized weakness, Review of the resident's Nutrition Risk assessment dated [DATE] showed: -A pertinent diagnosis of dysphagia (problems swallowing certain foods or liquids). -The resident was alert but unable to communicate. 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.

Based on observation, interview and record review, the facility failed to label foods in the resident use refrigerator, with the name of the resident(s) those foods belonged to. This practice potentially affected two residents who had food in that resident use refrigerator. The facility census was 58 residents. Review of the facility's policy entitled Foods Brought by Family/Visitors dated 7/17, showed: -Policy Statement: Food brought to the facility by visitors and family was permitted. Facility staff would strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents. -Family members and visitors were requested to inform nursing staff of their desire to bring foods into the facility. -Foods brought by family/visitors for individual residents may not be shared with or distributed to other residents. -Family/visitors were asked to prepare and transport food using safe food handling practices, including: safe cooling and reheating processes, holding temperatures, preventing cross-contamination with raw or undercooked foods; and hand…

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 prevent the presence of gnats (small flies) around the condiment area on a food storage shelf and under the dishwashing sink. This practice affected the kitchen. The facility census was 58 residents. 1. Observation on 9/25/23, showed the following: -At 9:29 A.M., many gnats flew around the shelf where the condiments were stored and containers of cider vinegar with several gnats in the cider vinegar -At 11:22 A.M., many gnats flew around the area under the dishwasher area, where there was grime on the pipes and a 1 foot (ft.) by long by 1 ft. wide opening in the wall under the dishwashing sink. During an interview on 9/25/23 at 1:07 P.M., the Director of Dining Service said he/she was not sure of the last time that area under the dishwasher was treated for gnats. During an interview on 9/26/23 at 1:45 P.M., the Director of Facility Operations said the opening on the wall under sink had existed for about a week prior to the survey and he/she saw that the wall needed to be repaired. He/she did not know the last time that 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 interview and record review, the facility failed to ensure the shift change narcotic (a drug that in moderate doses dulls the senses, relieves pain, and induces profound sleep but in excessive doses causes stupor, coma, or convulsions) count was completed and signed by both the on-coming and off-going nursing staff. The facility census was 52 residents. 1. Record review of the facilities Control Substances (a drug or other substance that is tightly controlled by the government because it may be abused or cause addiction) Policy revised December 2012 showed: -Nursing staff would count controlled medications at the end of each shift. -The nurse coming on duty and the nurse going off duty would make the count together. -They would document the count and reported and discrepancies to the Director of Nursing (DON). Record review of 100 Hall Narcotic Card Count sheet dated 1/8/22 thru 1/15/22 showed: -One out of 28 opportunities were not signed by either the oncoming or off going staff. -One out of 28 opportunities where the number of medication cards is not listed. Record review…

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 26 observed medication opportunities, five errors occurred resulting in an error rate of 19.23%. One medication involved crushing contents of a timed release capsule (Resident #20); one error involved an inhaler medication (Resident #1), one error involved an eye drop medication (Resident #45), one error involved insulin administration (Resident #12) and one error involved time of administration (Resident #43). The facility census was 52 residents. Record review of eye drop and inhaler administration information from the Certified Medication Technician (CMT) Student Manual, revised 2008 showed: -Hold the lower eye lid away from the eye to form a pouch. -Instill the eye drop into the pouch. -With a finger, apply pressure to the inside corner of the eye for one minute. -Wait at least one minute before giving a second inhalation (if ordered) of the same inhaler medication.;…

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 breathing inhalers were labeled with resident's name on the inhaler; to ensure eye drop vials were dated and labeled when opened; to monitor the medication refrigerator temperatures to ensure temperatures were maintained at appropriate levels for one medication refrigerator out of two medication refrigerators and to ensure acidophilus (a supplement that is used to help maintain the number of healthy bacteria) was refrigerated after opening for one sampled resident, (Resident #1). The facility census was 52 residents. Record review of facilities policy on Labeling of Medication Containers revised April of 2019 showed all medications maintained in the facility were properly labeled in accordance with current state and federal guidelines and regulations. Record review of the facility Storage of Medication policy, revised April 2019 showed: -Drugs and biologicals used in the facility are stored under proper temperature, light and humidity controls. -Medications requiring refrigeration are stored in 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.

Based on observation, interview and record review, the facility failed to: refrigerate open condiment containers; maintain in a sanitary condition a manual countertop can opener; keep cutting boards in good repair; keep spice containers clean an up-to-date; store foods covered, labeled and dated; ensure there were lids on trash cans available to use; and to ensure all kitchen food preparation employees were wearing hair restraints. These deficient practices of not practicing good hygienic and sanitation techniques and procedures, could potentially, promote microorganisms and bacterial growth which could adversely affect the health and well-being of the residents and staff who partook of the meals prepared by the dietary staff. The facility census was 52 residents at the time of the survey. 1. Observations on 4/18/22 between 5:35 A.M. and 8:38 A.M., in the kitchen, showed: -A one-half gallon container of soy sauce approximately ½ full that read, refrigerate after opening for quality, on the label, on a food shelf rack in the unrefrigerated, dry goods area. -A 4½ pound (approximately…

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 the resident's representative(s) in writing of a transfer or discharge to a hospital, including the reasons for the transfer and to provide the Ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) a copy of the notification for one sampled resident (Resident #9) out of 13 sampled residents and one closed record (Resident #49) out of two closed records. The facility census was 52 residents. 1. Record review of Resident #9's Profile Face Sheet showed he/she was admitted to the facility on [DATE]. Record review of the facility investigation dated 12/21/21 showed the resident was sent to the hospital after stepping off a sit to stand lift (are designed to assist patients who have some mobility but need help to rise from a sitting position. They allow caregivers to easily move patients from one seated surface to another) during a transfer. Record 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 interview and record review, the facility failed to notify the resident and the resident's representative in writing of the facility bed hold policy at the time of transfer for one sampled resident (Resident #9) out of 13 sampled residents and one closed record (Resident #49) out of two closed records. The facility census was 52 residents. Record review of the facility's undated Bed Hold Policy showed: -If a resident was absent for up to 18 days, no additional costs would be charged. -The residence (bed) would be held for 18 days. 1. Record review of Resident #9's Profile Face Sheet showed he/she was admitted to the facility on [DATE]. Record review of the facility investigation dated 12/21/21 showed the resident was sent to the hospital after stepping off a sit to stand lift (are designed to assist patients who have some mobility but need help to rise from a sitting position. They allow caregivers to easily move patients from one seated surface to another) during a transfer. Record 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 ensure completion of one resident's (Resident #20) left hip pressure ulcer (a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) treatment and to clarify/discontinue a treatment for the resident's right hip once the wound was healed, out of 13 sampled residents. The facility census was 52 residents. Record review of the facility Pressure Ulcer/Skin Breakdown - Clinical Protocol, revised April 2018 showed: -The licensed nurse would document all current treatments. -The physician would order pertinent wound treatments, including wound cleansing and debridement (the removal of dead or infected skin tissue to help a wound heal) approaches, dressings, and application of topical agents (substances which are applied to a body surface/wound). 1. Record review of Resident #20's Profile Face Sheet showed his/her current admission date…

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 residents were free from significant medication errors. One medication error occurred involving failure to properly prime an insulin pen (priming means removing the air from the needle and cartridge and ensures the pen is working correctly - if the pen is not primed before each injection, too little or too much insulin may be injected) prior to administration of insulin for one sampled resident (Resident #12). The facility census was 56 residents. Record review of the facility Insulin Administration policy, revised September 2014 showed: -The nursing staff will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery system(s) prior to their use. -Forms of insulin delivery included insulin pens. Record review of the facility Administering Medications policy, revised April 2019 showed: -Medications are administered in accordance with prescriber orders -The individual administering…

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.