Myers Nursing & Convalescent Center

Based on observation, interview and record review, the facility failed to ensure a physician ordered dietary supplement for weight loss was provided to one sampled resident (Resident #45) who had gradual weight loss out of 18 sampled residents. The facility census was 76 residents.1.Review of Resident #45's Face Sheet showed the resident was admitted with diagnoses including chronic obstructive pulmonary disease (COPD-a group of lung diseases that cause ongoing airflow obstruction and breathing problems) emphysema (a condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness). Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 5/19/25, showed the resident:-Was alert and oriented but had cognitive loss.-Was independent with eating and needed moderate assistance with bathing, hygiene and supervision with transfers.-Had no chewing or swallowing problems.-Had no significant weight loss during the lookback period. Review of the resident's Weight Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to obtain and transcribe physician orders for dialysis (is a treatment used to remove waste products and excess fluid from the blood when the kidneys are not functioning properly) services to include name of dialysis clinic, days of treatment, and failed to obtain physician orders for daily monitoring of the resident's dialysis shunt site (is a surgical connection between an artery and a vein that allows for the flow of blood during dialysis treatment) to assess the thrill (a vibration) and bruit (a whooshing sound) that indicates proper blood flow of the access site and to assess for bleeding at shunt site for one sampled resident (Resident #2) out 18 sampled resident. The facility resident census of 76 residents. A policy for dialysis was requested and not received at the time of exit. Review of the facility's Policy for Physician Order dated 2013 showed: -The licensed nurse documents the complete physician order onto the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two sampled residents (Resident #3 and Resident #5) medications were documented as administered as ordered by the physician out of 10 sampled residents. The facility census was 71 residents. Review of the facility's Medication Administration and Monitoring Policy dated 2025 showed: -To ensure quality of care delivery by instructing nursing staff to administer medications safely and appropriately. -Responsibility of nursing professional to: --Be aware of action, correct dosage and route, frequency and other considerations (pulse, blood pressure, meal) is required for administration of medications. --Notify physicians of any acute change in resident condition or status to obtain an order for holding or administering medication. --Coordinate communication between the pharmacy and the physician. --Report to the Director of Nursing (DON) when the resident refuses the medication on two consecutive occasions. -If the medications are not available from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to meet the required discharge requirements for one resident (Resident #1) out of three sampled residents. The facility census was 68 residents. Review of the facility's Protocol for Discharge Planned dated 2022 showed: -Residents who were admitted to the facility would be assessed for potentials upon admission, quarterly and whenever needed as wished or voice by the resident or facility professional staff. -The Quality Assurance (QA) committee discussed the potential discharge (immediate discharge, involuntary discharge) to investigate and analyze if the discharge was the best interest for the residents in the facility and/or for the resident who was discharged . -The QA committee would carefully monitor and discuss before making the decision and consult with the resident's primary physician, family or designated power of attorney (DPOA). When the committee agreed with the decision, the director of operations would be notified and discussed. -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 permit one sampled resident (Resident #1) to return to the facility out of three sampled residents. The facility census was 68 residents. 1. Review of Resident #1's admission Record face sheet showed he/he was admitted to the facility on [DATE] with the following diagnoses: -Anxiety disorder, (persistent and excessive worry about various aspects of life). -Depression, (a mental illness characterized by feelings of sadness, hopelessness and lack of interest or pleasure in activities once enjoyed). -Adjustment disorder, (a mental health condition characterized by emotional and behavioral symptoms in response to a stressor or group of stressors). -He/She was his/her own responsible party. Review of the resident's Care Plan dated 11/7/23 showed: -The resident had a diagnosis of depression and was being medicated and observed for it. -The resident did not have any care planning for behaviors. Review of the resident's Quarterly Minimum Data Set (MDS-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 have a Registered Nurse (RN) for eight consecutive hours a day for seven days a week, and failed to ensure the Director of Nursing (DON) did not serve as the charge nurse, when the facility maintained a daily census of more than 60 residents. This deficiency had the ability affect all residents. The facility census was 68 residents. Review of the facility's undated policy, titled Policy for Staffing showed: -A RN was required eight hours a day, seven days a week. -The DON was not to provide cares of treatments for residents unless the facility had 60 or less residents. 1. Review of DON's time sheet from 1/1/23-11/31/23 showed he/she did not work eight consecutive hours for 184 days out of 334 days. 2. Review of the facility's daily census showed the facility had greater than 60 residents during the survey. During an interview on 12/6/23 at 11:00 A.M., the Administrator said: -When the facility is short-staffed due to an employee not showing up, the DON will occasionally come in and work in their place. -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 Certified Nursing Assistants (CNAs) received yearly evaluations and education based on the result of those findings. This had the potential to affect all residents. The facility census was 68 residents. A copy of the facility's CNA yearly evaluation policy was requested and not received at time of exit. 1. A request for the evaluations and education of CNAs was made to the Administrator and not received at time of exit. During an interview on 12/6/23 at 11:00 A.M., the Administrator said: -He/she did not perform staff evaluations yearly. -He/she performed evaluations only when there was a problem. During an interview on 12/8/23 at 9:28 A.M., CNA B said: -He/she had worked at the facility for two years. -He/she had never had an evaluation.

Based on observation, interview, and record review, the facility failed to ensure staffing was posted correctly at the beginning of each shift including facility name, date, census, and the total number and actual hours worked per shift which could have the potential to affect all residents in the facility. The facility census was 68 residents. The facility's undated policy, titled Policy for Staffing showed a staffing board was required to be displayed in a public area. 1. Observation on 12/4/23 at 8:52 A.M. showed no staffing sheets posted at the front desk or either nurse station. Observation on 12/5/23 at 9:04 A.M. showed: -Staffing sheets were taped under the counter of both nurse stations, facing the staff, unable to be seen by residents or visitors. -Staffing sheets did not include the resident census or number of hours for each discipline. During an interview on 12/5/23 at 9:06 A.M., the Director of Nursing (DON) said: -He/she was responsible for posting the staffing sheets. -He/she posted staffing sheets at both the north and south nurse stations. -He/she had not had time…

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

Based on observation, interview and record review, the facility failed to follow the menu for breakfast on 12/7/23, by not serving cinnamon rolls according the menu for that day. This practice potentially affected all residents who received food from the kitchen. The facility census was 68 residents. 1. Record review of the Week 2 Week-at-a-Glance Menu, dated 2023, showed the following items for breakfast: - Assorted juice. - Choice of hot or cold cereal. - Egg of choice. - Bacon. - Cinnamon Roll. - Margarine. - Milk/Beverage. Observation on 12/7/23 from 8:15 A.M. through 8:42 A.M., during the breakfast meal service showed no cinnamon rolls were served with breakfast to any resident and no substitution was served to the residents. During an interview on 12/7/23 at 8:44 A.M., Dietary Aide (DA) C said there were no cinnamon rolls to serve during the breakfast meal that morning. During an interview on 12/8/23 at 2:14 P.M., the Dietary Manager (DM) said the following: - The facility's supplier of baked goods does not have cinnamon rolls. - The facility food delivery service did not have…

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

Based on interview and record review, the facility failed to submit accurate information to the Payroll Based Journal data (PBJ-a report that provides staffing dataset information submitted by nursing homes on a quarterly basis) for two of the last four quarters, which had the potential to affect all residents. The facility census was 68 residents. A copy of the Centers for Medicare and Medicaid (CMS) policy, dated August 2015, titled Electronic Staffing Data Submission Payroll-Based Journal showed: -Staff were required to submit accurate and timely information. -The nursing home was ultimately responsible for accuracy of each submission, even if the facility used a third party vendor to submit information on behalf of the nursing home. 1. Review of the facility's PBJ Quarter One (2023) from 10/1/22-12/31/22 showed no licensed nurse coverage 24 hours a day. Review of the facility's payroll, dated 10/1/22-12/31/22 showed a licensed nurse was on duty each shift. Review of the facility's PBJ Quarter Two (2023) from 1/1/23-3/31/23 showed no licensed nurse coverage 24 hours a day. 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.

Based on interview and record review, the facility failed to ensure the infection control tracking and trending was completed monthly. This had the potential to affect all residents in the facility. The facility census was 68 residents. Review of the facility's policy titled Infection Control Program-Surveillance dated from 2006 showed: -A system for surveillance was designed to establish and maintain a data base which describes endemic rates of nosocomial (facility-acquired) infections. -A systematic observation on the occurrence and distribution of facility-acquired infections among the residents for the purpose of prevention and control. -The term surveillance implies that the data has been compiled to be examined and reviewed in order to determine problems that may exist within a certain environment. -The process of surveillance: --Documenting baseline rates of endemic infections. --Identifying epidemics or other infection problems. --Convincing physicians or nursing home personnel of the seriousness of a particular problem. --The needs for vigorous control measures including…

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

Based on observation and interview, the facility failed to remove a buildup of dust from the ceiling tiles and ceiling vents in the north section of the dining room; to remove a buildup of dust from the ceiling vent in the North Hall shower room; to maintain a fan in resident room North Hall 21-24 free of a buildup of dust; and to remove a buildup of dust on the sprinkler head in North 19-20. This practice potentially affected at least 40 residents who used or resided in those areas. The facility census was 68 residents. 1. Observation on 12/5/23 at 10:31 A.M., with the Maintenance Director and the Regional Maintenance Director showed the presence of dust on the ceiling tiles and around the ceiling vents in the north section of the dining room. During an interview on 12/5/23 at 10:33 A.M. the Maintenance Director said he/she had only been employed at the facility for about two months and had not had a chance to get to clean the ceiling in the dining room. 2. Observation on 12/5/23 at 12:29 P.M., with the Maintenance Director and the Regional Maintenance Director showed a buildup 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 staff were aware of which employees were certified in cardiopulmonary resuscitation (CPR-a lifesaving technique useful in many emergencies, in which someone's breathing or heartbeat has stopped). This had the potential to affect all residents who required CPR. The facility census was 68 residents. A policy regarding staff CPR certification and staff scheduling was requested and not received at time of exit. 1. During an interview on [DATE] at 10:50 A.M., Certified Nursing Assistant (CNA) D said: -He/she was unsure what staff were CPR certified. -He/she did not know how he/she would know who was CPR certified. During an interview on [DATE] at 10:52 A.M., CNA A said: -He/she knew the people that attended CPR training with him/her were certified. -The facility did not have a list of what staff was certified. During an interview on [DATE] at 11:00 A.M., the Administrator said: -All nursing staff were CPR certified. A written request was made on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 4. Review of Resident #9's Face Sheet showed he/she was admitted on [DATE], with diagnoses including Alzheimer's Disease (progressive mental deterioration due to generalized degeneration of the brain), dementia (progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change), high blood pressure, diabetes (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), depression, seizure disorder (seizure is a sudden, uncontrolled burst of electrical activity in the brain) and arthritis(the swelling and tenderness of one or more joints). Review of the resident's annual MDS dated [DATE], showed the resident: -Was alert with cognitive incapacity and significant memory loss. -Preferences for activities included listening to music, participating in group activities. -Participating in…

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

Based on interview and record review, the facility failed to ensure all narcotics were accounted for by not having the on-going and off-going nurses sign the Controlled Substance Log during shift change or document the amount of each medication left. This had the potential to affect all residents that received narcotics. The facility census was 68 residents. Review of the facility's policy, dated 6/9/22, titled Protocol for Managing the MAR (Medication Administration Record)/Narcotics Records showed: -At shift change, both the on-going and off-going nurse were to review the medication cards and sign out sheets. -Every pill was to be accounted for on the sign-out sheet. 1. Review of the facility's Shift Change Controlled Substance Check Sheet for November 2023 for the North Hall showed: -Missing signatures 9 out of 40 opportunities. -The medication count was not recorded 17 out of 20 opportunities. Review of the facility's Shift Change Controlled Substance Check Sheet for November 2023 for the South Hall showed: -Missing signatures 27 out of 182 opportunities. -The medication count…

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 medication error rate was less than 5% with a medication error rate of 8.82% which affected one sampled resident (Resident #60) and one supplemental resident (Resident #66) out of 21 sampled residents and nine supplemental residents. The facility census was 68 residents. A policy related to medication administration was requested and not received at the time of exit. Review of the facility's policy titled Insulin Administration dated from 2007 showed no policy or procedure for the use of insulin pens. 1. Review of Resident #66's admission Minimum Data Set (MDS-a federally mandated assessment tool to be used for care planning), dated 10/9/23, showed: -The resident had moderate cognitive impairment. -The resident had Diabetes Mellitus (a disease that results in too much sugar in the blood). Review of the resident's Physician Order Sheet (POS), dated December 2023, showed the physician ordered Lispro (a type of fast-acting insulin…

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 remove a buildup of dust on the baffle vents (metal devices which trap oil and grease that makes it into the kitchen's atmosphere by passing air through a series of interlocking baffles) of the range hood (an open metal enclosure over cooking surfaces through which air is drawn in from the surrounding spaces to exhaust heat and grease, and to control the flow of rising hot air into the range hood and filter grease ); to remove a buildup of dust on the walls ceiling and pipes of the kitchen including over food preparation areas; to remove food debris from the floor under the Refrigerators #1 and #2 and Freezer #2; to ensure Dietary Aide (DA) A did not handle clean dishes after handling soiled dishes without washing/his/her hands or changing gloves; to ensure DA B handled cups with drinks which were going to be served to residents, without placing his/her fingers in the cups; and to have a trash container that was opened through the activation of a foot operated lid opening system. This practice potentially affected 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 interview and record review, the facility failed to ensure the infection control antibiotic stewardship (the effort to measure and improve how antibiotics are prescribed by clinicians and used by patients/residents) was completed monthly. This had the potential to affect all residents in the facility. The facility census was 68 residents. A copy of the facility's policy related to antibiotic stewardship was requested and not received at the time of exit. 1. Review of the facility's infection control log dated March 2023 showed no documentation of antibiotic stewardship for that month. Review of the facility's infection control of dated October 2023 showed: -A list of two residents that were on antibiotics. -The antibiotics that each resident was on. -There was no documentation related to why the antibiotics were prescribed. Review of the facility's infection control log dated November 2023 showed no documentation of antibiotic stewardship for that month. During an interview on 12/6/23 at 11:25 A.M. the Infection Preventionist (also the MDS-a federally mandated assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain the fan in the laundry room free of a buildup of dust; to remove a buildup of dust from under the vending machines in the dining room; to ensure the light fixture in the North Hall shower room was installed properly; to maintain the mirror in North room [ROOM NUMBER]-24; and to maintain the light fixture in North 1-2 in good repair. This practice potentially affected 50 residents who resided on the North Hall and used the dining room. The facility census was 68 residents. 1. Observation on 12/5/23 at 10:03 A.M., with the Maintenance Director and the Regional Maintenance Director showed a buildup of dust on the fan in the laundry. During an interview on 12/5/23 at 10:03 A.M., the Regional Maintenance Director said the fan was not cleaned in the past, but the fan would be cleaned going forward. During an interview on 12/8/23 at 11:54 A.M., the Housekeeping Supervisor said he/she had not cleaned the fan in the laundry in a while. 2. Observation on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to prevent the existence of mice and mouse droppings in the following resident rooms: North Hall room [ROOM NUMBER]-28, North Hall room [ROOM NUMBER]-20, North Hall 13-14, North Hall room [ROOM NUMBER]-8, South room [ROOM NUMBER]-44, South room [ROOM NUMBER]-36, South room [ROOM NUMBER]-12, South room [ROOM NUMBER]-32, South room [ROOM NUMBER]-28, South room [ROOM NUMBER]--20, and South room [ROOM NUMBER]-24. This practice potentially affected 26 residents who resided in those rooms. The facility census was 68 residents. 1. Observation on 12/5/23, with the Maintenance Director and the Regional Maintenance Director, showed: - At 12:48 P.M., mouse droppings were present on the floor behind the bed in North Hall room [ROOM NUMBER]-28. - At 1:05 P.M. mouse droppings were present on the floor and behind the bed in North Hall room [ROOM NUMBER]-20. - At 1:18 P.M., mouse droppings were present on the floor in North room [ROOM NUMBER]-14. - At 1:27 P.M., mouse…

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 Certified Nursing Assistants (CNAs) received 12 hours of in-service education (which was to include abuse, neglect, and dementia training) per year by not being able to produce documentation for all CNAs, not providing adequate training, and not monitoring what education CNAs had received. This had to potential to affect all residents. The facility census was 68 residents. Review of the facility's undated policy titled Abuse/Neglect Training and Orientation showed: -All current and newly hired employees were to be in-serviced with the Abuse/Neglect Hot Topic In-Service recommended by the Department of Aging and the pages in the CNA Course Manual currently used by the state. -Employees were to receive training upon hire and a minimum of twice a year. -Copies were to be placed in the employee's file. 1. Review of the facility's in-services showed: -No dementia training documented for the year. -Abuse and neglect training was provided on 11/29/23 but not all CNAs were in attendance. -The summary of abuse and neglect…

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 call light was within reach for two sampled residents (Resident #41 and #15) out of 21 sampled residents. The facility census was 68 residents. Review of the facility's policy, dated 2/21/12, titled Answering of Call Lights and Alarms showed the policy did not address resident access to call lights. 1. Review of Resident #41's Quarterly Minimum Data Set (MDS-a federally mandated tool used for care planning), dated 9/15/23, showed: -The resident had moderate cognitive impairment. -The resident had a diagnosis of paraplegia (the loss of muscle function in the lower half of the body, including both legs). Review of the resident's undated care plan showed: -The resident was totally dependent on staff for dressing. -The resident required a mechanic lift for transferring. -The resident was non-weight bearing. Observation on 12/5/23 at 11:32 A.M. showed: -The resident was in his/her room in a wheelchair. -The call light was behind the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the emergency contact was notified of one sampled resident's transfer to the hospital when the resident had a change in condition for one closed record sample (Resident #39) out of 21 sampled residents. The facility census was 68 residents. 1. Review of the Resident #39's Face Sheet showed the resident was admitted to the facility on [DATE], with diagnoses including depression, arthritis, high blood pressure, kidney failure (a condition in which the kidneys are damaged and cannot filter blood as well as they should), diabetes (a disease in which the body' s ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), hypo-osmolality (a condition where the levels of electrolytes, proteins, and nutrients in the blood are lower than normal) and hyponatremia (a lower than normal level of sodium in the bloodstream), acidosis (a condition in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a Pre admission Screening and Resident Review (PASARR-a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis who apply or resident in Medicaid Certified beds in a nursing facility regardless of the source of payment) was completed for one supplemental Resident (Resident #4) out of 21 sampled residents and 8 supplemental residents. The facility census was 68 residents. Review of the facility's undated policy titled PASARR Policy showed: -The screening assures appropriate placement of persons known or suspected of having mental impairment(s) and also that the individual needs of mentally impaired persons can be and are being met in the appropriate placement environment. -All potential admitting residents will be assessed by the Social Services Director (SSD) and/or nursing staff to complete the PASARR. 1. Review of Resident #4's Face Sheet 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 interview and record review, the facility failed to ensure a recapitulation of the resident's stay (describes the resident's course of treatment while at the facility) was completed for one sampled resident (Resident #72) out of 21 sampled residents. The facility census was 68 residents. A policy for Recapitulation of Stay was requested and not received at the time of exit. 1. Review of Resident #72's Face Sheet showed he/she admitted to the facility on [DATE] with the following diagnoses: -Seizures (a sudden, uncontrolled burst of electrical activity in the brain causing changes in behavior, movements, feelings, and levels of consciousness). -Hypertension (High Blood Pressure) -Obsessive Compulsive Disorder (OCD- a personality disorder characterized by excessive orderliness, perfectionism, attention to details, and need for control in relating to others). Review of the resident's discharge Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff 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.

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 #15) was bathed a minimum of twice a week to maintain adequate hygiene, out of 21 sampled residents. The facility census was 68 residents. A policy regarding bathing was requested and not received at time of exit. 1. Review of Resident #15's Discharge Assessment Minimum Data Set (MDS-a federally mandated tool used for care planning), dated 11/10/23, showed the resident was transferred to the hospital. Review of the resident's Entry Tracking Record MDS, dated [DATE], showed the resident returned from the hospital. Review of the resident's Significant Change MDS, dated [DATE], showed: -The resident was now on hospice services (end of life care). -The resident was rarely/never understood. -The resident was always incontinent of bowel and bladder. Review of the resident's undated Care Plan showed: -Staff documented the resident was totally dependent on staff for bathing, dressing, eating, hygiene,…

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 skin assessments were being completed and documented for one sampled resident (Resident #66) out of 21 sampled residents. The facility census was 68 residents. A facility policy on skin assessments was requested and not received at the time of exit. 1. Review of Resident #66's Face Sheet showed he/she admitted to the facility with the following diagnoses: -Hemiplegia (paralysis to one side of the body) following Unspecified Cerebrovascular (relating to the brain and its blood vessels) Disease Affecting the Right Dominant Side. -Coronary Artery Disease (CAD- plaque build-up in the wall of the arteries that supply blood to the heart) without Angina Pectoris (chest pain). -Diabetes Mellitus (DM II- a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). Review of the resident's Skin Monitoring: Comprehensive Certified Nursing Assistant (CNA) Shower Review dated 10/2/23 showed: -The…

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

Based on observation, interview, and record review, the facility failed to ensure the treatments were being completed and documented for one sampled resident (Resident #12) who had a newly developed pressure ulcer (an injury to the skin and underlying tissue resulting from prolonged pressure on the skin) out of 21 sampled residents. The facility census was 68 residents. Review of the facility's undated policy titled Ulcer Documentation showed proper documentation is necessary for medical, legal, and reimbursement reasons. Review of the facility's Weekly Wound Assessment Sheet dated from 2007 showed: -The following were Nursing Interventions to be completed: --Follow the treatment order and document the wound description. --Monitor the healing process. --Support pressure relieved position and provide pressure relieved devices. -Document on the wound daily/weekly until healed. 1. Review of Resident #12's Face Sheet showed he/she admitted to the facility with the following diagnoses: -Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow physician's orders for providing health shake supplements, to complete Dietary/Nutritional Assessments annually and to monitor the resident's dietary needs as needed for one sampled resident (Resident #9) who had a history of weight loss out of 21 sampled residents. The facility census was 68 residents. Review of the facility Physician's Orders policy and procedure dated 2013, showed: -Nursing was to transcribe all physician's orders to the Physician Order Sheet (POS) and note the medication, dosage, route, resident, and time. -Transcribe the order to the appropriate administration record. Requested facility dietary policy was not received at the time of exit. 1. Review of Resident #9's Face Sheet showed he/she was admitted on [DATE], with diagnoses including Alzheimer's Disease (progressive mental deterioration due to generalized degeneration of the brain), dementia (progressive or persistent loss of intellectual functioning,…

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 physician's order for oxygen was documented on the resident's Physician's Order Sheet (POS) that included the amount and duration oxygen should be administered, when tubing and supplies should be changed for one sampled resident (Resident #45); to ensure oxygen tubing, nasal cannula, and nebulizer (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) mouthpiece were kept covered when not in use to prevent contamination for one sampled resident (Resident #45) and one supplemental resident (Resident #32); and to monitor to ensure the humidifier bottle was kept clean and sanitary for one sampled resident (Resident #45) out of 21 sampled residents. The facility census was 68 residents. Review of the facility Physician's Orders policy and procedure dated 2013, showed: -Nursing was to transcribe all physician's orders to the POS and note the medication, dosage, route, resident, and time.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medications kept in one resident room were stored in a locked compartment; and to ensure the resident that had medication in his/her room had an order to self-administer the medication for one sampled resident (Resident #68) out of 21 sampled residents. The facility census was 68 residents. Review of the facility's policy, dated 6/5/23, titled Storage of Medication at the Resident's Bedside showed: -The physician was required to write may keep at bedside for each medication that the resident was allowed to keep in his/her room. -Staff were to ensure any medications kept at bedside were stored in a locked drawer or box to prevent other residents from having access to the medication. 1. Review of Resident #68's Face Sheet showed he/she was admitted on [DATE]. Review of the resident's Self Administration of Inhaler, dated 10/19/23, showed: -Staff observed the resident self-administer his/her Spiriva (a medication that is delivered…

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 pureed (cooked food, usually vegetables, fruits or legumes, that has been ground, pressed, blended or sieved to the consistency of a creamy paste or liquid) chicken was processed according to the recipe on 12/4/23; to monitor the temperature of the pureed chicken to ensure the chicken was served at a temperature of 120 ºF (degrees Fahrenheit) on 12/4/23; and to follow the recipe for pureed eggs and pureed sausage on 12/7/23. This practice potentially affected one sampled resident (Resident #15) out of 21 sampled residents who had physician's orders for a pureed diet. The facility census was 68 residents. 1. Review of Resident #15's Physician's Order Sheet (POS) dated 12/23, showed a physician's order for the resident to have a diet of pureed food consistency. Review of the resident's significant change Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning) dated 11/15/23 showed the following: - A resident for which a Brief Interview for Mental Status…

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 denied one sampled resident (Resident #2) visitation privileges in or out of the facility and to assist with finding other solutions with his/her justice involved domestic partner of 22 years out of eight sampled residents. The facility census was 64 residents. Review of the facility's Resident Rights policy dated 5/10/23 showed: -The resident has a right to a dignified existence, self-determination, and communication with access to persons and services inside and outside the facility. -The facility must protect and promote the rights of each resident, including: --The resident has the right to exercise his or her rights as a resident of the facility and citizen or resident of the United States. --The resident has the right to be free from interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights. -Access and Visitation Rights: -The facility must provide reasonable access to any resident by any entity or individual…

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 one Nursing Assistant (NA) (Employee K) completed the Certified Nurse Assistant (CNA) training program within four months of his/her employment in the facility. The facility census was 66 residents. 1. During an interview on 6/6/22 at 11:37 A.M., Employee K said he/She had taken some CNA training and needs to finish. Record review of the facility staffing roster on 6/7/22 showed: -Employee K's date of hire was 5/15/20. -He/she worked on the following days: --6/1/22 day shift. --6/2/22 day shift. --6/3/22 day shift. --6/6/22 day shift. --6/7/22 day shift. Observations from 6/1/22 to 6/7/22 of Employee K showed: -He/she was going in and out of resident's rooms. -He/she would take clean briefs (underwear for incontinence) into resident's rooms. -He/she was assisting resident's in wheelchairs to and from the dining room. During an interview on 6/8/22 at 11:20 A.M., the Administrator said: -Employee K was hired on 5/15/20. -As of 6/8/22 he/she had not completed a CNA training program. During an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the annual 12 hours of in-service training and staff competencies for the nursing staff including the Certified Nurse Assistant's (CNA) required 12 hours of in-service education and based on performance reviews annually. The facility census was 66 residents. Requested the facility policy for In-services and at the time of exit had not received it. 1. Record review of the facility's Facility assessment dated 2022 showed: -To determine what resources were necessary to care for residents competently during both day-to-day operations and emergencies. -The Assessment helped to make the decisions about the facility's capacity and needs to provide services to residents, including the staff competencies (specific training). -Resources to provide care include staff competencies to continue training staff and assess for educational needs. Record review of in-services staff received in the last 12 months showed: -[DATE]th, 2021: Abuse & Neglect; Geri…

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 keep the kitchen, Dry Storage, and walk-in refrigerator floors clean; failed to retain operable thermometers in all refrigerators/freezers to confirm adequate temperature ranges; failed to maintain sanitary utensils and food preparation equipment; and failed to keep trash and garbage receptacles lidded. These deficient practices potentially affected all residents, visitors, volunteers, or staff who ate food from the kitchen. The facility's census was 66 residents with a licensed capacity for 84 residents. 1. Observations during the initial kitchen inspection on 6/1/22 between 9:00 A.M. and 11:56 A.M. showed the following: -The walk-in refrigerator off the Dry Storage room had onion peels, dried food debris, and a bread wrapper clip on the floor. -The Dry Storage room had scraps of paper and a bread wrapper clip under the racks. -An unlidded 5-gallon bucket next to the tilt-skillet was almost full with a dark liquid, trash, and food scraps inside, and an abundance of dried liquid splatters on the outside. -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 meet the requirements for a comprehensive, facility-specific infection prevention and control program designed to help prevent the development and transmission of water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease), including documented assessments for such an outbreak and a plan to deal with them, in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who reside, visit, use, or work in the facility; to ensure staff used proper hand hygiene techniques during medication pass; failed to document whether a resident had signs or symptoms of tuberculosis for one sampled resident (Resident #12) out 17 sampled residents; and to ensure staff followed source control measures to help mitigate the spread of COVID-19 when 29 facility staff and one contract staff, including seven unvaccinated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow standard trash and garbage disposal practices to mitigate the presence of common household pests (for example, bed bugs, lice, roaches, ants, mosquitoes, flies/gnats, mice, and/or rats), and to maintain an effective pest control program with adequate measures to eradicate those pests when present. These deficient practices potentially affected all residents, visitors, volunteers, and staff who resided, visited, used, or worked in the facility. The facility's census was 66 residents with a licensed capacity for 84 residents. 1. Record review of the last three exterminator's invoices to the facility provided by the Corporate Maintenance Director (CMD), showed the following: -The treatment dates were 3/22/22, 4/20/22, and 5/11/22. -The invoice for 3/22/22 listed the service as Monthly Pest Control. -The areas treated were listed as the exterior of the building, interior common areas, restrooms, the kitchen, resident rooms on both the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the residents had the ability to participate in a resident council where they would be able to express grievances and make recommendations concerning issues of resident care and life in the facility for five sampled residents (Resident's #2, #40, #45, #65 and #58) out of 17 sampled residents. This deficiency has the potential to affect all cognitively intact residents. The facility census was 66 residents. Record review of Centers for Medicare and Medicaid services (CMS) guidance for activities showed: -August 31, 2020: --Phase 1: Restrict group activities, but some activities may be conducted (for COVID-19 (a new disease caused by a novel (new) coronavirus that emerged in December 2019, led to severe social restrictions beginning in March 2020 and led to a pandemic)negative or asymptomatic residents only) with social distancing, hand hygiene, and use of a cloth face covering or facemask. --Phase 2: Group activities, including outings, limited…

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 resident safety by not conducting appropriate background screenings for new employees to include the checking of the Nurse Aide Registry (a data base that provides the list of eligible nursing assistants who can be employed by long-term care facilities as health workers) for possible Federal Indicators (FI) for six out of nine new employees. This practice had the potential to affect all residents, employees and visitors to the facility. The facility census was 66 residents. Record review of the facility's undated Policy on Employee Disqualification List (EDL) and Criminal Background Check (CBC) for Employees showed: -All CBC and EDL shall be completed no longer that five days prior to the first employment day. -EDL check, criminal background check, license or certification verification for hired staff on any restrictions for practice must be complete prior to hiring. -All registry information shall be mailed to the Family Care Safety Registry (FCSR) within 15 days of hire. -Keep track of mailing record by the log.…

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 reassess the effectiveness of interventions, review and revise the resident's care plan with input from the resident or resident representative for three sampled residents (Resident's #45, #2, and #13) out of 17 sampled residents. The facility census was 66 residents. 1. Record review of Resident #45's face sheet, dated 9/13/21, showed: -The resident was admitted to the facility on [DATE]. -The resident had a legal Guardian. -The resident's diagnoses included schizophrenia (a chronic mental illness that interferes with a person's ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions, and relate to others) and intellectual disabilities (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses). Record review of the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure each resident's medications had a documented diagnosis or symptom on the Physician's Order Sheet (POS) for each medication for two sampled residents (Resident's #58 and #13) and to ensure one sampled resident (Resident #64) had an order to keep his/her inhaler at his/her bedside and self administer the inhaler out of 17 sampled residents. The facility census was 66 residents. Record review of the facility's policy for physician order showed: -A licensed nurse was responsible for reviewing the last month's POS, Medication Administration Records (MARs), Treatment Administration Records (TARs), physician telephone orders, etc. to the new month's documents for accuracy). -The policy did not include a requirement of having an appropriate diagnosis for each prescribed medication. 1. Record review of Resident #58's face sheet showed he/she moved into the facility on [DATE]. Record review of the resident's June 2022 POS showed there was no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide an ongoing activity program based on a comprehensive assessment and care plan of each resident's interests for nine sampled residents (Resident's #13 #58, #41, #45, #2, #34, #56, #60, and #65) out of 17 sampled residents. The facility census was 66 residents. Record review of the facility's Activity Policy dated 2000 showed: -Activities were any activity other than Activities of Daily Living (ADLs-dressing, grooming, bathing, eating, and toileting) that a resident pursued in order to enhance a sense of well-being. -The activity program should be revised, reviewed often and tailored to each resident's individual needs. -Activities provide increased self-esteem, pleasure, comfort, education, creativity, success and financial or emotional independence. -Activities can provide stimulation or solace. -Activities can provide spiritual well-being. -Activities promote physical, cognitive and/or emotional health. -Activities enhance…

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

Based on observation, interview and record review, the facility failed to ensure staffing information was posted in a prominent place, readily accessible to residents and visitors of the daily resident census, or the number of nursing staff for each shift. This practice had the potential to affect residents and visitors who were inquiring about the facility staffing hours. The facility census was 66 residents. A copy of the facility staffing policy was requested. The facility provided a copy of the Facility Assessment only. Record review of the Facility assessment dated 2022 showed: -The Facility Wide Assessment helps to make decisions about the facility's capacity and needs to provide services to residents. -Resources to provide care included staffing plan and staff types. -The Assessment did not include any information on posting of staffing on a daily basis with the resident census or the number of nursing staff for each shift. 1. Observations from 6/1/22 to 6/8/22 showed: -No nursing staffing sheet posted at main reception desk. -No nursing staffing sheet posted at the main…

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 narcotic count sheet was signed by both the on-coming and the off-going staff; to verify the correct count of narcotics; and to ensure the narcotic count sheet was not pre signed before the end of a shift, resulting in an error in the count for one resident (Resident #53). The facility census was 66 residents. Record review of the facility Policy for Management of Schedule II medication (medications with a high potential for abuse, with use potentially leading to severe psychological or physical dependence) dated 2010 showed: -All controlled medications shall be checked and counted each shift by two licensed nurses. -The counting record shall be kept separately from other medication records. -The licensed nurse will count the medications with the on-coming shift licensed nurse and document on the provided sheet with both licensed signatures. -A missing or discrepancy in counting shall be notified immediately to the Director of Nursing (DON)…

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 medication refrigerators which held residents' insulin pens and stock vaccines were checked by the nursing staff to ensure the temperature was within range: to ensure the medication refrigerator was clean; to ensure the sink in the medication room was clean; to ensure staff was not pre setting medications prior to medication pass, and to ensure the medication carts were kept locked when staff were not actively working with the mediation cart and did not have direct eyesight of the cart. The facility census was 66 residents. Record review of facility's policy Medication Storage, Handling and labeling Daily Practice Standards dated 3/13 showed: -The medication room was to have been kept clean. -The medication refrigerator temperature was to register between 36 degrees Fahrenheit (F) to 46 degrees F and was to be noted daily on the Refrigerator temperature daily log. -The medication and treatment carts were to be locked when not in use. Record review of a notice to all Nurses and Certified 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain a Durable Power of Attorney (DPOA-a person previously identified to make decisions for an individual in the event of inability to make wishes known) or have a plan in place for two cognitively impaired residents (Resident's #34 and #60) who were unable to make day to day decisions due to cognitive impairment out of 17 sampled residents. The facility census was 66 residents. 1. Record review of Resident #34's admission Record showed: -He/she was admitted on [DATE]. -He/she was listed as a Full Code (allows all interventions needed to restore breathing or heart functioning). -He/she was listed as his/her own responsible party (a person who has responsibility for all or a portion of the patient's healthcare and can include the patient, a guardian or other guarantor (responsible party)). -He/she had no contacts listed. -He/she had the following diagnoses: --Dementia (a general term for a decline in mental ability resulting in memory loss, and other…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to investigate the missing narcotic medication Tramadol HCl(a controlled opioid used to treat moderate to severe pain in adults) for one sampled resident (Resident #53) out of 17 sampled residents. The facility census was 66 residents. Record review of the facility Policy for Management of Schedule II medication dated 2010 showed: -All controlled medications shall be checked and counted each shift by two licensed nurses. -The counting record shall be kept separately from other medication records. -The licensed nurse will count the medications with the on-coming shift licensed nurse and document on the provided sheet with both licensed signatures. -A missing or discrepancy in counting shall be notified immediately to the Director of Nursing (DON) or the Administrator. -The DON and the Administrator shall initiate the investigation immediately. -Upon investigation, any serious violation (stealing) against the Missouri State Board of Nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure there were physician's orders for full side rails, that were documented as a restraint (a device or other means of limiting movement) on both sides of the bed and per facility policy, to have a nurse or physical therapist re-assess when the resident could no longer assist with bed mobility and the continued use of full side rails on both sides of the bed for two sampled residents (Resident's #41 and #23) out of 17 sampled residents. The facility census was 66 residents. Record review of facility's physical restraint policy dated 2007 showed: -If a restricted device is needed to enhance resident mobility and serve as an enabler, for positioning and/or supporting posture, an evaluation shall be completed by a licensed nurse. -Assessments can be done by a physical therapist or a licensed nurse to identify the medical symptom/condition. Record review of the facility's side rails policy dated 2021 showed if a side rail meets 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 send a transfer/discharge notice in writing to one sampled resident (Resident #50) or his/her family when he/she was transferred to the hospital out of 17 sampled residents. The facility census was 66 residents. Record review of the facility's undated policy, Transfer/Discharge, showed: -A transfer or discharge from the facility would take place when the transfer was necessary to meet the resident's welfare the and resident's welfare could not be met in the facility. -The resident was given the reason for transfer and the effective date of transfer. -If known, the family member, surrogate, or legal representative would be notified. -A written notice of transfer was made so as to allow appropriate arrangement. -The notice must have been provided at least 30 days prior to the transfer except if it was a resident's urgent medical needs that required a more immediate transfer. 1. Record review of Resident #50's face sheet showed he/she was admitted on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to send a bed hold policy in writing to one sampled resident (Resident #50) or his/her family when he/she was transferred to the hospital out of 17 sampled residents. The facility census was 66 residents. Record review of the facility's policy, Bed-hold and readmission dated 2018 showed: -At the time of a transfer of a resident for hospitalization the facility would provide to the resident and a family member or legal representative written notice which specifies the duration of the bed-hold policy. 1. Record review of Resident #50's face sheet showed he/she was admitted on [DATE] and was his/her own person had the following diagnoses: -Polyosteoarthritis (a joint disease involving at lest five joints). -History of traumatic fracture (broken bones caused by impact or falls). -Anemia (a condition in which the blood does not have enough red cells). -Anorexia (an eating disorder where people abscess about what they eat). -Hearing loss. 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 the accuracy of the Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff and used for care planning) for two sampled residents (Residents #41 and #58) out of 17 sampled residents. The facility census was 66 residents. 1. Record review of Resident #41's care plan last reviewed 1/17/22 showed he/she had side rail restraints (any manual method or physical or mechanical device, material or equipment attached to or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body) for movement assistance and fall prevention. Record review of the resident's quarterly MDS dated [DATE] showed two side rail restraints were used daily and the resident was totally dependent upon staff for bed mobility. Record review of the resident's June 2022 Physician's Order Sheet (POS) showed there were no orders for side rails. Observation on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure current orders were documented on the Physician Order Sheet (POS) and Medication Administration Record (MAR) and to clarify orders with the physician after the Pharmacists review/recommendation for one sampled resident (Resident #14); and to administer pain medication as ordered for one sampled resident (Resident #53) out of 17 sampled residents. The facility census was 66 residents. Record review of the facility's Policy for Physician Order dated 2013 showed: -To ensure the accuracy of transcribing an order. -To have physician orders transcribed from the POS to the appropriate administration record. -The POS will be reviewed by a licensed nurse monthly during the changeover (assuring all orders are correct on the POS for the following month) to capture all information for the next month. -The POS will be reviewed by the physician/Nurse Practitioner (NP) monthly to ensure the appropriate treatment and orders. -The pharmacy consultant will 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 one sampled resident (Resident #41) was provided with staff supervision, a smoking apron and assistance while smoking out of 17 sampled residents. The facility census was 66 residents. Record review of the facility's smoking policy dated 2018 showed: -Smoking was permitted under the supervision of facility staff only in the designated smoking areas in the building, where posted, and during designated smoking times for those residents that exhibit risk behaviors. -Residents who were with physical limitation should be assessed for safely smoking with or without assistance and monitor. -Safe smoking ability is completed yearly or on quarterly assessment and when the resident has a change in condition to ensure the resident's smoking ability to be safe. The interdisciplinary team will determine the frequency of assessment. -Assess residents' safe smoking behavior. -Determine needs for safety such as a smoking apron/jacket and/or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure non-pharmacological interventions were documented as used prior to pain medications being documented as given for one sampled resident (Resident #55) out of 17 sampled residents. The facility census was 66 residents. Record Review of the facility Pain Assessment Policy dated 2013 showed: -Nursing staff were responsible for pain management. -Pharmacological management included the scheduled pain medication and as needed (PRN) pain medication. -Non-Pharmacological interventions included activities, massage, soft pillow or mattress, relaxation, and breathing techniques. -Staff were to complete pain assessments. -Staff were to review pain medications and contact the physician if the resident continued to complain of pain. -Staff were to provide non-pharmacological techniques to help alleviate pain. 1. Record review of Resident #55's undated face sheet showed he/she was admitted on [DATE] with the following diagnoses: -Venous Insufficiency (when 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 one sampled resident (Resident #40) was provided with lab services and was able to have his/her labs drawn twice a week in order to maintain a therapeutic level of Coumadin (an anticoagulant (blood thinner) used to treat or prevent blood clots) and to notify the resident's physician regarding the resident's labs and to ensure one sampled resident's (Resident #14) order for Lorazepam (Ativan-a controlled medication used to treat anxiety) was transcribed from the April 2022 monthly Physician Order Summary (POS) to the May and June POS and the Medication Administration Record (MAR) or have a discontinued order written out of 17 sampled residents. The facility census was 66 residents. Record review of the facility's laboratory services policy dated 12/2/04 showed: -It was the responsibility of nursing professionals to ensure all lab services were completed and results provided to the facility within timeframes normal for appropriate…

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.