Summit, The

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure perineal (peri) care was provided as needed for one sampled resident (Resident #3) out of 24 sampled residents. The facility census was 56 residents. Review of the facility's policy titled Policy for Daily Activities of Daily Living (ADL) dated 2024 showed bed mobility care is performed daily every 2 hours for limited mobility residents and every 4-6 hours depending on tissue tolerance and whenever needed. 1. Review of Resident #3 admission Record showed he/she was admitted on [DATE], with the following diagnoses:-Unspecified Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses).-Type 2 Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure an individualized activity plan was goal directed and incorporated the interest and ability of one sampled resident (Resident #20) out of 24 sampled residents. The facility census was 56 residents. Review of the facility Activity policy dated 2022, showed:-The purpose to ensure residents receive meaningful activities. To ensure assessments for activities preferences are completed on admission. To ensure progress documentation of activity assessment. -Provide a plan of activities appropriate to the needs of the residents. -Assess resident needs and develop resident activities goals for the written care plan. -Encourage resident participation in activities and document outcomes. -Review goals and progress notes. -Properly document Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff for care planning) reports and progress notes. Develop a plan of care addressing activity preferences and services.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 physician orders were followed regarding a medical device being placed by proper personnel and administered as ordered for one sampled resident (Resident #1) that was not supposed to be self-administered out of 24 sampled residents. The facility census was 56 residents.Review of the facility's Medication Administration policy and procedure dated 2024, showed there was no policy or procedure for administering treatments or medical equipment or devices. Review of the facility's Self Administration policy and procedure dated 2018, showed there was no policy or procedure for self-administering medical equipment or devices.1. Review of Resident #1's Face Sheet showed the resident was admitted on [DATE], with diagnoses including end stage renal disease (ESRD a condition where the kidneys are damaged and cannot filter blood effectively), left leg fracture, depression, anxiety disorder, high cholesterol, low iron, and dependence on dialysis…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident smoking materials were stored safely for one sampled resident (Resident #40); failed to ensure a safe smoking environment after a resident fell asleep while holding a lit cigarette; failed to re-assess the resident for safe smoking; and failed to develop care plan interventions to prevent the incident from recurring for one sampled resident (Resident #42), out of 24 sampled residents. The facility census was 56 residents. Review of the facility's Smoking Policy dated 2022 showed:-The resident's Safe Smoking ability was to be completed yearly or on quarterly assessments.-Assess resident's safe smoking behavior. Determine needs for safety such as a smoking apron, 1:1 supervision and address in the care plan. -Smoking policy given to the resident at the time of admission and signed by the resident or responsible party to acknowledge understanding of the policy. -Staff will round every hour to monitor resident who are…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 physician's orders for self-administration and care for a colostomy (a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon) were obtained and documented on the Physician's Order Sheet (POS) for one sampled resident (Resident #13) out of 24 sampled residents. The facility census was 56 residents.Review of the facility's undated Ostomy-Colostomy policy and procedure showed the purpose was to prevent infection and ensure proper drainage, enhancing hygiene and dignity. It showed:-The resident will be informed of care for the (colostomy).-A resident who is able to perform self-care will be provided information and education on (colostomy) care. -There was no procedure or documentation showing how physician's orders should be written for self-care of the colostomy. 1. Review of Resident #13's Face Sheet showed the resident was admitted to the facility on [DATE] with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to thoroughly assess the resident's chewing and swallowing ability, failed to re-assess the resident's dietary need and preferences to address the resident's weight and eating status and failed to care plan recent weight loss and nutritional interventions for one sampled resident (Resident #13) with gradual weight loss out of 24 sampled residents. The facility census was 56 residents.Review of the facility's Unplanned Weight Management policy and procedure dated 2006, showed the purpose was to ensure each resident received appropriate nutritional care and ensure significant weight loss or gain be addressed and clinically managed. It showed:-The Director of Nursing (DON)/Assistant Director of Nursing (ADON) will be responsible for establishing a monthly/weekly weight schedule.-The appointed nursing staff responsible for weighing will compare the current weight and the previous weight and shall re-weigh if there is a 5-pound variance.-The weight…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 physician's orders were followed for monitoring and documenting one sampled resident's (Resident #1) dialysis access site (a surgically created pathway that allows blood to be removed from and returned to the body during hemodialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally) out of 24 sampled residents. The facility census was 56 residents.Review of the facility's undated Dialysis policy and procedure showed staff was to:-Palpate (to feel) the vascular access to feel for a thrill (vibration) that indicates arterial and venous blood flow and patency.-Auscultate (to listen) the vascular access with a stethoscope (a medical instrument for listening to the action of someone's heart, breathing or internal system) to detect a bruit (swishing sound) that indicates patency.-Check the patient's circulation by palpating the pulses further…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 refrigerator temperatures were checked daily and documented on the facility temperature log sheet to maintain safe storage of temperature controlled refrigerated medication; and failed to ensure to medication refrigerators were cleaned as scheduled and free of spills. This deficient practice had the potential to affect all residents with medication stored in the medication refrigerators. The facility census was 56 residents.Review of the facility's Storage of Medications policy dated 2024 showed:-Medications are to be stored in a safe, secure, and orderly manner.-Drugs are to be stored at proper temperatures. -Temperature logs are to be completed daily by the 11:00 P.M. -7:00 A.M. night shift. 1. Observation on 7/31/25 at 9:59 A.M of the facility second floor medication room showed:-The current refrigerator temperature was 34 degrees.-The refrigerator side door and inside had a sticky purplish substance noted. -The temperature log for July 2025 had 10 missing temperatures out 30…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 wound care treatments and skin assessments were completed and documented for one sampled resident (Resident #3) out of five sampled residents. The facility census was 55 residents. Review of the facility's policy titled Non-Pressure Ulcer Assessment and Treatment dated from 2006 showed: -The purpose of the policy was to maintain skin integrity and prevent any type of wound development. -All non-pressure ulcers would be assessed and documented weekly using the provided form. -All residents would be assessed every thirty days for skin integrity. -All non-pressure wounds would be treated according to physician order. -Skin screenings were done according to bath schedule. -Assessment weekly/monthly or more frequent would occur as instructed by the Registered Nurse (RN) or Director of Nursing (DON). -A focused assessment should be completed of the wound area. -Communicate among shifts of progress and healing. -Provide treatment per physician order not limited to pain or infection. 1. Review of Resident #3's admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that wound care treatments were completed and documented including weekly wound tracking and measuring was completed for one sampled resident (Resident #2) who had pressure ulcers (an injury to the skin and underlying tissue resulting from prolonged pressure on the skin); and failed to ensure weekly skin assessments were completed and documented for one sampled resident (Resident #1) out of five sampled residents. The facility census was 55 residents. Review of the facility's policy titled Pressure Ulcer Treatment Policy and Procedure dated from 2006 showed: -Staff were to assess pressure ulcers by using the wound assessment form weekly and for any change in condition. -The staff were to use appropriate topical therapy per physician order or recommendation from wound care specialists. -The staff were to monitor skin surfaces daily and document on the appropriate form. Review of the facility's policy titled Ulcer Documentation dated from 2006…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 fall investigations were complete and thorough to include root-cause analysis (RCA- a collective term that describes a wide range of approaches, tools, and techniques used to uncover causes of problems) for three sampled residents (Resident #1, Resident #4, and Resident #5) out of five sampled residents. The facility census was 55 residents. Review of the facility's policy titled Policy and Procedures for Fall Investigation dated from 2006 showed: -Licensed nurses perform an assessment within a time frame appropriate to the clinical circumstance, right after a fall has occurred and coordinate other indicated evaluation and management of injuries or underlying causative conditions. -Licensed nurses completed the fall investigation upon each fall on the provided form. -The safety committee reviewed the fall incident and would make a referral by physical therapy (PT)/ occupational therapy (OT) or enrolled the resident into restorative…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 protective oversight for one sampled resident (Resident #1) when Certified Nursing Assistant (CNA) A exploited the resident by cultivating a relationship with him/her who was hearing impaired, took the resident from the facility to hi/her bank out of state, attained access to the resident's accounts without an American Sign Language (ASL) or Certified Deaf Interpreter (CDI) present, then used the access to the resident's account to withdraw $24,952.83 out of three sampled residents. The facility census was 64 residents. Review of the facility's undated Abuse and Neglect Policy showed: -Financial or material exploitation, illegal or improper use of an individual's funds, property, or assets without informed consent and resulting in monetary, personal or other benefit, gain, or profit for the perpetrator, or monetary or personal loss by the individual. --Utilizing position of authority to take advantage of an individual for personal gain.…

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

Based on observation, interview, and record review, the facility failed to ensure staffing was posted at the beginning of each shift that included the resident census, the current date, the total numbers and actual hours worked for all licensed and unlicensed staff that provided direct care to residents, and to display it in a way that was readily accessible to residents and visitors to view. This had the ability to effect all residents. The facility census was 54 residents. Review of the facility's policy, dated 2023, titled Policy for Staffing showed: -A staffing board was to be displayed in a public area and include the number of licensed and unlicensed direct care staff. -The staffing board was to be visible to visitors and others. -A form, with areas for all the required information, was attached. 1. Observation on 9/10/23 at 11:05 A.M. showed: -The monthly staff schedule was taped to the top of the front desk. -The schedule did not indicate number of hours for each position, the resident census, or the current date. During an interview on 9/10/23 at 11:05 A.M., Licensed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 was adequate dietary staff to ensure the breakfast meal on 9/10/23, was served on time and to ensure dietary staff used the proper cooking equipment (baking pans for chicken) to ensure the lunch meal was served timely on 9/11/23. This practice potentially affected all residents. The facility census was 54 residents. 1. Review of an Undated sign in the dining room showed the following: -Meal Times: --Breakfast - 8:00 A.M. --Lunch - 12:00 P.M. --Dinner - 5:00 P.M. 2. Review of Resident #42's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning), dated 7/7/23, showed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15. During an interview on 9/10/23 at 11:13 A.M., the resident said: -On 9/10/23 it was really rough, the staffing was an issue because of no cook for breakfast. -That day the nursing staff had to cook breakfast.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 do or maintain the following: maintain the automated dishwasher free of food debris inside the nozzles of the dishwasher spray wands; to protect open bowls of fruit and cottage cheese by not placing a cover on those items within the reach-in refrigerator; place a date on the tray that the ground meat in the reach-in refrigerator, was removed from the freezer; place a date on the bag of shredded cheese as to when that bag was opened; remove the food debris and grease buildup from the floor behind the 6-burner stove; remove a buildup of grime and food debris from the bottom of the reach-in refrigerator; discard a bag of lettuce in which the lettuce began to turn to brown; remove two spatulas with handles which were not easily cleanable from service; and remove food debris from under the reach-in refrigerators. This practice potentially affected all residents. The facility census was 54 residents. 1. Observations on 9/10/23 from 11:29 A.M. though 11:57 A.M., showed: -The presence of food debris inside the nozzles of the spray…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 three of the last four quarters, which had the potential to affect all residents. The facility census was 54 residents. No policy regarding PBJ submissions was received at time of exit. 1. Review of the facility's PBJ Quarter Three (2022) from 4/1/22-6/30/22 showed no data submitted for the quarter. Review of the facility's PBJ Quarter Four (2022) from 7/1/22-9/30/22 showed no Registered Nurse (RN) hours and no licensed nurse coverage 24 hours a day. Review of the facility's PBJ Quarter Two (2023) from 1/1/23-3/31/23 showed the facility failed to have a licensed nurse in the facility 24 hours a day. Review of the facility's working schedules for Quarter Four (2022) and Quarter Two (2023) showed: -A licensed nurse was in the building 24 hours a day. -A RN worked at least eight hours each day. During an interview on 9/12/23 at 8:50 A.M., the Administrator…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 comply with the requirements of a waterborne illness prevention program by failing to having an annual backflow prevention test (a test to find out if the one-way gate that allows water from the city's public water supply to flow into a building's piping but stops water if it ever tries to flow backwards into the main water supply, was working properly) and by failing to develop a specific waterborne illness prevention plan for that facility by failing to conduct a facility specific risk assessment to find out where opportunistic waterborne pathogens could grow; failed to formulate a diagram to indicate which hot water heaters would distribute water to distinct sections of the facility; failed to include testing protocols to ensure that control measures to prevent the growth and spread of the Legionella (a [NAME] of pathogenic gram-negative bacteria that includes the species L. pneumophila, causing legionellosis including a pneumonia-type illness…

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

Based on interview and record review, the facility failed to have a process to monitor antibiotic usage including prescribing and documentation of the indication, dosage, and duration of the use of antibiotics. This failure had the potential to affect all residents at the facility. The facility census was 54 residents. Review of the facility's policy titled Antibiotic Stewardship Policy dated from 2021 showed: -Antibiotic Stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. -Antibiotic Stewardship can be accomplished through improving antibiotic prescribing, administration, and management practices thus reducing inappropriate use to ensure that residents receive the right antibiotic for the right indication, dose, and duration. -Apply the McGeer revised criteria (a set of symptoms required to indicate the use of an antibiotic) for assessing the suspected infection. -Using worksheet for suspected infection to indicate the McGeer revised criteria and report to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to have a process in place to ensure staff were aware of who was certified in cardiopulmonary resuscitation (CPR-an emergency procedure consisting of chest compressions often combined with artificial ventilation, or mouth to mouth, in an effort to preserve intact brain function until further measures are taken). The facility census was 54 residents. 1. Review of the facility's policy, dated 2023, titled Policy for Medical Emergency Response showed the facility was to maintain a record of any staff who were trained and capable of performing CPR. During an interview on [DATE] at 1:25 P.M., the Administrator in Training (AIT) said: -He/she made the staff schedules. -All staff in the building, including non-nursing staff, were CPR certified. -Staff knew everyone in the building was CPR certified. During an interview on [DATE] at 1:48 P.M., Licensed Practical Nurse (LPN) C said all staff in the building were CPR certified. Review of the facility's undated CPR…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident's privacy by failing to ensure the privacy curtain was operable and was able to be used to provide privacy to one sampled resident (Resident #404) out of 14 sampled residents. The facility census was 54 residents. 1. Review of Resident #404's Face Sheet showed he/she was admitted to the facility on [DATE], with diagnoses including respiratory failure, cerebral palsy (a condition marked by impaired muscle coordination and/or other disabilities, typically caused by damage to the brain before or at birth), abnormal mobility and gait, muscle weakness, abnormal posture and high blood pressure. 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 7/5/23, showed the resident: -Needed extensive assistance for bathing, dressing, transferring and mobility. -Needed the assistance of two staff for transfers and was incontinent of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to assess one sampled resident for a seatbelt to determine if it was a restraint or a safety device, to obtain a physician's order for the device and to care plan the seatbelt if needed for one sampled resident (Resident #404) out of 14 sampled residents. The facility census was 54 residents. Review of the facility's Physical Restraint policy and procedure updated 2023, showed a physical restraint is an item used to restrain or prevent the movement of a person. These devices include belts .Whether or not a particular item is considered a physical restraint depends on the purpose and effect of its use. The same item may not be used as a restraint if it is used to enable a resident in some way. The procedure showed: -Staff should complete a risk assessment upon admission. -If a restricted device is needed to enhance resident mobility and serve as an enabler, for positioning and posture, an evaluation shall be completed by a licensed nurse. -An…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 bed hold forms were completed for three sampled residents (Resident #48, #28, and #403) out of 14 sampled residents. The facility census was 54 residents. Review of the facility's policy titled Bed Hold Policy and Readmission dated from 2021 showed at the time of transfer of a resident for hospitalization or therapeutic leave, the facility will provide to the resident and a family member or legal representative written notice which specifies the duration of the bed-hold policy. 1. Review of Resident #48's face sheet showed he/she was admitted with the following diagnoses: -Type 2 Diabetes Mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high). -End Stage Renal Disease (condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). Review of the resident's Discharge 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) was completed accurately and in a timely manner for three sampled resident (Resident #48, #9, and #403) out of 14 sampled residents. The facility census was 54 residents. Review of the facility's policy, Resident Assessment Instrument (RAI - helps the facility staff to gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan) Process Protocol dated from 2023 showed: -The MDS Coordinator and the Director of Nursing (DON) are responsible to review the completion of MDS items. -Randomly reviewed by DON or administrator to ensure the timely completion (monthly, quarterly, or Pro Re Nata (PRN) per DON's discretion). -The DON will be responsible to implement and monitor this system by monthly reviewing the online report (missing assessments reports and MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to include one sampled resident (Resident #48) when completing their care plan; and to ensure care plans were updated to reflect the resident's correct status for one sampled resident (Resident #403) out of 14 sampled residents. The facility census was 54 residents. Review of the facility's policy, dated 2023, titled RAI [Resident Assessment Instrument] Process Protocol showed: -The care plan team was to consist of all nursing disciplines, social services, dietary, activities, and other therapies as applicable. -Resident inclusion is not addressed. A policy specifically related to care plans was requested and not received at the time of exit. 1. Review of Resident #48's face sheet showed he/she was admitted with the following diagnoses: -Type 2 Diabetes Mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high). -End Stage Renal Disease (condition in which a person's kidneys cease functioning on a permanent basis…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 to complete Annual or quarterly Smoking Safety Assessment to assess the resident's ability to safely smoke unsupervised and to ensure to monitor and assess safe storage of smoking material for one sampled resident (Resident #18), who had a known history of smoking in non-designated smoking areas, out 14 sampled residents. The facility census of 54 residents. Review of the Smoking Safety Assessment form created 2018 showed: -Complete resident Smoking Safe Assessment quarterly, yearly and whenever condition change that affect the resident safety. -Assessment Criteria include: --Express understanding of the facility smoking rule and policy. --Holding cigarette properly (finger not close to fire or ashes). --Using an ashtray properly when disposing ashes. --Falls asleep during smoking. --Easily distracted when smoking. --Turn off and remove oxygen related devices when smoking. --Smokes in room or other prohibited areas. --Able to use…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to obtain a physician's order for the resident's colostomy (or ostomy, is a surgical a hole (stoma) in the abdominal wall allows waste to leave the body. A colostomy or ostomy bag attaches to the stoma to collect the waste) care and monitoring of the stoma site; to obtain a physician's order for the resident to provide his/her own colostomy self-care; and to obtain and maintain ongoing nursing assessment of the resident's ability to provide own colostomy self-care for one sampled resident (Resident #18) out of 14 sampled residents. The facility census of 54 residents. Review of the facility's Policy for Colostomy Care dated 2023 showed: -To ensure proper colostomy care that prevents infection and injury. -Nursing care shall maintain integrity of the stoma and skin surrounding the stoma. -Nursing care shall observe for any changes in the bowel pattern or size of the stoma. -Nursing shall assess the stoma for the following: stoma type,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 identify, assess, and treat one sampled resident (Resident #34) with continued gradual weight loss with significant dental issues resulting in a 6.4% weight loss in three months and an 8% weight loss in six months, and to develop and implement a care plan for the resident with interventions related to the gradual weight loss and dental issues, out of 14 sampled residents. The facility census was 54 residents. Review of the facility's Nutritional Management Program dated 2023 showed: -The Director of Nursing (DON) or the Assistant Director of Nursing (ADON) would be responsible to establish a monthly and weekly weight schedule. -The staff responsible for weighing will compare the current weight and the previous weight and shall re-weigh if the weight of 5 pounds (lbs) in variance. -The weight record shall be communicated with the Quality Assurance Committee and the Weight Committee upon completion. -Residents who were observed declining 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 observation, interview and record review, the facility failed to transcribe physician's order to the resident's Treatment Administration Record (TAR) for monitoring the resident's Arteriovenous (AV) shunt (is access site, were a abnormal connections between coronary arteries and a compartment of the venous side of the heart) used for dialysis (is a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) treatments and failed to ensure to follow the physician's order and document monitoring AV shunt assessment on TAR each shift and on the AV shunt assessment form daily, and failed to provide this resident dialysis contract for review for one sampled resident (Resident #12) out of 14 sampled residents. The facility's census was 54 residents. A policy for dialysis and dialysis contract was requested and not received at the time of exit. Review of the facility's Monitor Internal AV Shunt Patency Daily Form revised on 2016 showed: -Assessment include the date of assessment, site of the shunt, distal thrill (feels like buzzing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 appropriate behavioral management for one sampled resident (Resident #50) out of 14 sampled residents. The facility census was 54 residents. Review of the facility's policy titled Behavior Management Program dated from 2023 showed: -The term behavior symptom is defined as an indication or characteristic of a negative physical or psychosocial outcome, which may indicate negative interactions or negative attitude that result in unpleasant atmospheres and disturbs others. -A change in behavior includes any abnormal or unusual pattern of behavior symptoms including increase or decrease the severity. -Residents who exhibit behavior symptom concerns will be monitored and/or treated to prevent incident. -Monitoring should include check pattern, occurrence. -Treatment intervention should include pharmaceutical interventions and non-pharmaceutical interventions. -The care plan should be revised for new interventions and monitoring process.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accurately care plan and assist one sampled resident (Resident #48), out of 14 sampled residents, in obtaining routine dental care services. The facility census was 54 residents. Review of the facility's policy, dated 2023, titled Ancillary Services showed: -Staff were to follow the physician's order, arrange the appointment, and arrange transportation. -Staff were to address dental concerns in the resident's care plan. -The Minimum Data Set (MDS-a federally mandated tool used for care planning) was to reflect any dental concerns. -Staff were to periodically assess each resident's teeth. 1. Review of Resident #48's face sheet showed he/she was admitted with the following diagnoses: -Type 2 Diabetes Mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high). -End Stage Renal Disease (condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of…

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

Based on interview and record review, the facility failed to ensure that the resident's preference of non-lactose milk was available for one sampled resident (Resident #500) for a period of 17 days. The facility census was 54 residents. 1. Review of Resident #500's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning), dated 7/29/23, showed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15. Review of the resident's face sheet dated 9/1/23, showed diagnoses which included Crohn's Disease (a type of inflammatory bowel disease (IBD) which caused swelling of the tissues (inflammation) in the digestive tract, which could lead to abdominal pain, severe diarrhea, fatigue, weight loss and malnutrition). During an interview on 9/10/23 at 11:57 A.M., the resident said -He/she could not drink the regular milk that was served that day. -He/she wanted hot water to mix with his/her packet of cereal because the cereal served that day had regular milk in it. -No one from the kitchen gave…

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

Based on observation, interview and record review, the facility failed to ensure that food stored in the 2nd floor refrigerator used to store food for residents brought in by visitors, was labeled with the resident's name and dated with the date the food was brought in. This practice potentially affected at least three residents who have food stored in the refrigerator. The facility census was 54 residents. Review of the facility's policy entitled Policy Regarding Use and Storage of Foods Brought to Residents by Family and Other Visitors, dated 2019, showed: -Purpose: To ensure the resident's safety while using foods that are not provided by the facility. -The nursing home follows the directions of regulatory requirements and food safety requirements of F 812 and F 813. -The nursing home allows residents to choose to accept food from any friends, family, visitors or other guests. -The facility also is responsible for storing food brought in by family or visitors in a way that is either separate or easily distinguishable from facility food. -The facility nursing home staff 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 ensure the lid for the outdoor dumpster was kept closed when it was not in use. This practice potentially affected an unknown number of residents who used the outdoor patio for smoking which the dumpster was adjacent to. The facility census was 54 residents. 1. Observations on 9/10/23 at 11:06 A.M. and at 1:18 P.M., showed the right side lid of the dumpster was lifted to the open position. 2. Observations on 9/11/23 at 8:08 A.M., 10:12 A.M., 12:15 P.M. and 1:47 P.M., showed the right side lid of the dumpster was lifted to the open position. During an interview on 9/11/23 at 1:48 P.M., the Dietary Manager (DM) said the dumpster lid was used by different departments and they do not close the lid like they should. During an interview on 9/11/23 at 1:32 P.M., the Corporate Maintenance Person said the reason why the lid was left open from time to time was because some facility staff do not want to take the time to open the lid when they bring the trash out to the dumpster. During an interview on 9/12/23 at 2:25 P.M., 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 follow physician's orders for rehabilitation services in a timely manner for one sampled resident (Resident #5) out of 14 sampled residents. The facility census was 54 residents. Review of the facility's policy, dated 2023, titled Policy for Ancillary Services showed staff were to ensure all services were offered in a timely manner. 1. Review of Resident #5's face sheet showed he/she was admitted on [DATE] with rheumatoid arthritis (chronic inflammation of the joints) and generalized muscle weakness. Review of the resident's Care Plan, dated 8/15/23, showed: -Staff documented the resident had limited mobility related to arthritis. -The resident was totally dependent on staff for locomotion using his/her wheelchair. 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 8/17/23, showed: -The resident had a mild cognitive impairment. -The resident required…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 menu substitutions were reviewed and revised as needed by the Registered Dietitians (RD) or the menu company when facility dietary staff substituted food items for what was written on the menu on three different occasions. This practice potentially affected all residents. The facility census was 51 residents. 1. Record review of the breakfast menu for Wednesday, Day 4 of Week 1 for 7/20/22 showed assorted Juice, hot or cold cereal, sausage gravy and biscuits, margarine and beverage. Observation on 7/20/22 from 7:11 A.M. through 8:40 A.M. showed Dietary [NAME] (DC) A substituted eggs for the sausage and substituted French Toast sticks for the biscuits. Observation on 7/20/22 at 7:18 A.M., showed DC A placed French Toast sticks on a baking sheet. During an interview on 7/20/22 at 7:19 A.M., DC A said there were not any biscuits or sausage patties in the walk-in freezer. During a phone interview on 7/26/22 at 11:09 A.M., the Interim Dietary Manager (DM) said: - For the breakfast meal on 7/20/22, 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 lowest shelf in the reach-in fridge was free of grime; to remove debris from under the ice machine; to remove debris from the nozzles of the dishwasher spray wand; to ensure the single light bulb in the walk-in ridge was illuminated; to prevent the buildup of debris on the floor of the dry goods storage room; and to ensure thermometer probe wipes were available for use. This practice potentially affected all residents. The facility census was 51 residents. 1. Observations during the initial kitchen review on 7/18/22 from 9:17 A.M. through 9:31 A.M., showed: - The presence of grime on bottom of the fridge. - The presence of the debris under the ice machine. - The presence of debris inside the nozzles of the dishwasher spray wands. - The presence of debris on floor of walk-in fridge debris on floor of dry goods storage room. - The presence of debris under the reach-in fridge. - The lone light bulb in the walk-in fridge, did not illuminate. 2. Observation of the breakfast meal preparation on 7/20/22…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an on-going monitoring facility-wide Infection Prevention Control Program (IPCP) was established; to ensure surveillance logs were maintained for seven months out of 12 months surveillance to include but not limited to: monitor, track, and identify trends of infections in the facility; and to screen and maintain documentation for tuberculosis (TB - a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, and abnormal lung tissue and function) for 2 of 8 sampled employees. This had the potential to affect all residents who had infections or who were at potential risk for infections. The facility's census was 51 residents. Record review of the facility policy for Infection Control Surveillance, revised 2006 showed: -Surveillance including process and outcome surveillance, monitoring, data analysis, documentation and communicable disease reporting. -To establish a systematic observation on the occurrence and destruction of facility-acquired infections…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 received mail on mail delivery days as identified by the United States Postal Service, including Saturdays, and mail that was not opened for two sampled residents (Resident #12 and #6) and one supplemental resident (Resident #33) out of 15 sampled residents and nine supplemental residents. This had the potential to affect all residents. The facility census was 51 residents. The facility failed to provide any policy regarding mail delivery after receiving a request on 7/21/22. 1. Record review of Resident #12's Face Sheet showed he/she was admitted [DATE] with a diagnosis of Congestive Heart Failure (CHF a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues). Record review of the resident's annual Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff used for care planning) dated 3/22/22 showed: -The resident had a Brief Interview for Mental Status (BIMS)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain the resident rooms 210, 209, 217, 202, free from a buildup of dust and debris on the floors; to maintain the fans in resident rooms 213, 207, 218, 220, 201, 108, and 101 free from a heavy buildup of dust on the fan blades of those fans; to maintain the commode seats and commode risers (an extender to an existing toilet, under or over the lid, that lifts the seat height to a more comfortable level for residents who may be disabled) free from damage or rusty areas in resident rooms 214, 219 and 221; to maintain the ceiling vents free from a heavy buildup of dust in the restrooms of 215, 103, and 111; to maintain the ceiling tiles and ceiling vents over the main dining room free from dust; and to maintain the floor of 2nd floor resident use vending machine area free from food debris and insects. This practice potentially affected at least 40 residents who resided in or used those areas. The facility census was 51 residents. 1. Record…

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

Based on interview and record review, the facility failed to ensure all employees were screened through the Nurse Aide Registry as part of the facility screening for Employee Disqualification List (EDL) and Criminal Background Check (CBC) procedure upon hiring new employees for 4 of 8 sampled employee records. The facility census was 51 residents. Record review of the Facility's Policy for Checking New Hired Employees dated 2022, showed the facility would make an inquiry to the Missouri Department of Health and Senior Services to whether the employee is listed on the employee disqualification registry, and would follow state laws and federal guidelines regarding employee background review upon employment as part of the facility's hiring procedures. 1. Record review of eight sampled employee personnel files for the purpose of completing the criminal background check and employee disqualification listing portion of the survey process on 7/22/22, showed the following employee records did not include the Nurse Aide Registry check as part of the employee background screening: -Licensed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 comprehensive Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) were completed and submitted timely for three supplemental residents (Residents #1, #7, and #38), out of 15 sampled residents and nine supplemental residents. The facility census was 51 residents. Record review of the facility policy Resident Assessment Instrument (RAI - helps the facility staff to gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan) Process Protocol dated 2022 showed: -Purpose: To ensure the accuracy and timeliness of all MDS assessments; to reassess the significant change statue; to develop a comprehensive care plan that reflects level of care delivery to meet resident needs; to maintain an accurate tracking record of admission, readmission, and discharge status; and to be compliant with the regulatory requirement for certifying 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 quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) were completed and submitted timely for two sampled residents (Resident #11 and #10) and four supplemental residents (Resident #4, #2, #3, and #5) out of 15 sampled residents and nine supplemental residents. The facility census was 51 residents. Record review of the facility policy Resident Assessment Instrument (RAI - helps the facility staff to gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan) Process Protocol dated 2022 showed: -Purpose: To ensure the accuracy and timeliness of all MDS assessments; to reassess the significant change statue; to develop a comprehensive care plan that reflects level of care delivery to meet resident needs; to maintain an accurate tracking record of admission, readmission, and discharge status; and to be compliant with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to electronically transmit encoded Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) from the facility to the Centers for Medicare & Medicaid Services (CMS) system within 14 days after completion for two sampled residents (Resident #11 and #10) and seven supplemental residents (Residents #4, #1, #7, #2, #3, #5, and #38) out of 15 residents sampled residents and nine supplemental residents. The facility had a census of 51 residents. Record review of the facility policy Resident Assessment Instrument (RAI - helps the facility staff to gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan) Process Protocol dated 2022 showed: -Purpose: To ensure the accuracy and timeliness of all MDS assessments; to reassess the significant change statue; to develop a comprehensive care plan that reflects level of care delivery to meet resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the accuracy of the comprehensive assessments for two sampled residents (Residents #30 and #45) out of 15 sampled residents and nine supplemental residents. The facility census was 51 residents. Record review of the facility policy Resident Assessment Instrument (RAI - helps the facility staff to gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan) Process Protocol dated 2022 showed: -Purpose: To ensure the accuracy and timeliness of all Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) assessments; to reassess the significant change statue; to develop a comprehensive care plan that reflects level of care delivery to meet resident needs; to maintain an accurate tracking record of admission, readmission, and discharge status; and to be compliant with the regulatory requirement for certifying the accurate 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, interview and record review, the facility failed to ensure residents had complete, accurate and individualized care plans, to address the specific needs of the residents, for one sampled resident (Resident #12); to ensure an individualized comprehensive care plan was developed in regards to pain, oxygen, and diuretics (any drug that increases urination) for one sampled resident (Resident #9 ) and to develop and implement an individualized comprehensive care plan for behavioral monitoring including target behaviors for one sampled resident (Resident #10) who received psychotropic medications (drugs which affect psychic function, behavior, or experience) out of 15 sampled residents and 9 supplemental residents. The census was 51 residents. Record review of facility Policy for Care Plan dated 2022 showed care plan should address all side effects and monitoring process and care provided for all medications that require intensive attention: psychotropic, anticoagulant, diabetic agents, diuretic,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 fall investigation; to reassess the resident's fall risk and mobility status after the resident fell and to create and update a care plan that showed the resident fall interventions for one sampled resident (Resident #45).The facility failed to ensure ongoing monitoring and assessment system in place, to assess the resident ability to smoke safely without supervision and ability to safely store smoking material in residents room and to complete and implement a comprehensive smoking care plan for five sampled residents (Resident #32, Resident #19, Resident #35, Resident #11 and Resident #6) out of 15 sampled residents. The facility census was 51 residents. Record review of the facility's Fall Policy/Procedure dated 2022 showed: -Licensed nurses assess resident's on admission annually, after acute falls to identify diseases and conditions posing a risk for falls, diseases and conditions that predispose…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 cover trash containers in the kitchen and the dining room during the breakfast meal on 7/20/22. This practice potentially affected at least 25 residents who used the dining room on 7/20/22. The facility census was 51 residents. 1. Observations on 7/20/22 from 7:11 A.M. through 8:40 A.M., showed the trash container in the kitchen and the trash container in the dining room were uncovered during that time. During an interview on 7/20/22 at 8:43 A.M., Dietary [NAME] (DC) A said they do not have covers for the trash containers. Observation on 7/20/22 at 8:48 A.M. showed trash container in dining room and the trash container in the kitchen were uncovered. Record review of the 2009 Food and Drug Administration (FDA) Food Code Chapter 5-501.110 entitled Storing Refuse, Recyclables, and Returnables, showed: Refuse, recyclables, and returnables shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents. Chapter 5-501.113 entitled Covering Receptacles, showed: Receptacles…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to take measures to prevent the existence of numerous flies in the kitchen, and to prevent the existence of bedbugs (small, oval, brownish insects that live on the blood of animals or humans which are flat bodied and about the size of an apple seed) in Resident room [ROOM NUMBER] and in the rooms of Residents #7 and #6. The facility census was 51 residents. 1. Observations during the breakfast meal preparation on 7/20/22 from 7:11 A.M. through 8:23 A.M., showed the following: - The presence of numerous flies in the kitchen. - The door between the Main Dining Room (MDR) and the outdoor smoking patio, was cracked open. - Uncovered trash container in the dining room and an uncovered trash container in the kitchen. During an interview on 7/20/22 at 8:44 A.M., Dietary [NAME] (DC) A said the following: - The flies came in from the outside through the door from the smoking patio. - He/she said he noticed a lot of flies in the kitchen that day as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to establish and implement a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights that include the residents were free from retaliation after filing a grievance for one sampled resident (Resident #6) and one supplemental resident (Resident #33) out of 15 sampled residents and nine supplemental resident's. The facility censes was 51 residents. Grievance policy requested 7/21/22 and not received. 1. Record review of Resident #6's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Major depressive disorder (a mental disorder characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts). -Anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome). 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 interview and record review, the facility failed to notify the resident 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 of transfer or discharge for three sampled residents (Resident #32, #45, and #10) out of 15 sampled residents. The facility census was 51 residents. Record review of the facility's Transfer and Discharge policy dated 2022 showed: -All residents who are discharged or transferred under any circumstances will be reported to the local ombudsmen. -If the resident discharge/transfers to emergency room or hospital for short period of time and anticipated return within 24 hours, the facility can log the short transfer/discharge to the local ombudsman monthly. -Resident condition for transfer/discharge. -Provide written instruction with verbal explanation (if appropriate) 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 record review and interview, the facility failed to provide written notification of the facility's bed hold policy to three sampled residents (Resident #32, #45, and #10) and/or responsible party upon discharge/transfer to the hospital, out of 15 sampled residents. The facility census was 51 residents. Record review of the facility's Notice of Bed Hold policy and readmission form (provided to the resident/responsible party) showed the facility's bed hold policy and procedure which stated in part: -Bed Hold for days in excess of the Missouri's Bed-Hold limit is considered to be a non- covered service meaning you or your legal representative can pay for the bed hold out of your pocket. -The facility's bed hold policy permits your return if your absence is beyond the Missouri Medicaid Bed Hold Policy. -You can also return to the facility if a new resident has not taken that bed. -If your bed is no longer available, you will be entitled to the first available bed at the facility in accordance with the 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 complete a Significant Change Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning), for one sampled resident (Resident #44) who started on dialysis treatments (a process of purifying the blood of a person whose kidneys are not working normally) out of 15 sampled residents. The facility census was 51 residents. 1. Record review of Resident #44's Face Sheet showed he/she was admitted on [DATE] with diagnoses including kidney disease, high blood pressure, prostate cancer, and vitamin D deficiency. Record review of the resident's admission MDS dated [DATE], showed the resident: -Was alert and oriented with no memory loss. -Needed no assistance with hygiene, walking and eating and was continent. -Needed supervision with dressing and limited assistance with transfers, bed mobility, toileting and needed extensive assistance with bathing. -Used a walker for mobility and had no range of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the residents were assessed for activity preferences in the comprehensive assessment and the care plan, as well as provide an ongoing program to support the residents in their choice of activities for three sampled residents (Resident #6, #12, and #28) out of 15 sampled residents. The facility census was 51 residents. Record review of the facility's Activity Policy dated 2022 showed: -Staff were to allot at least 30 minutes of time per resident per week for activities duties. -The facility was to provide a monthly activity calendar to residents and inform the resident groups of activities daily. -The facility was to prepare a monthly calendar of activities in large print and post in a prominent location. -Care plans were to address activity preferences and services. -Documentation of activities were to be done quarterly on an activity progress note. 1. Record review of Resident #6's Face Sheet showed he/she was admitted to the…

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

Based on interview, and record review, the facility failed to ensure that a process was in place to confirm that skin assessments and wound monitoring was being completed for one sampled resident (Resident #30) out of 15 sampled residents. The facility census was 51 residents. A policy was requested for skin assessments and wound monitoring but was not received from the facility at the time of exit. 1. Record Review of Resident #30's Hospice (end of life care) admittance sheet dated 5/13/21 showed the resident was admitted with the following diagnoses: -Muscle wasting and atrophy (the thinning of muscle mass). -Chronic Kidney Disease (CKD when the kidneys are gradually less able to function). -Type two Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency of insulin production). Record review of the resident's Nurse Note dated 6/10/22 at 1:30 A.M. showed: -The resident climbed into bed himself/herself while an unknown Certified Nursing Assistant (CNA) was present in the room. -The resident sustained a skin tear…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 proper oxygen tubing storage for two sampled residents (Resident #32 and #9) and to have a physician order for the use of oxygen for one sampled resident (Resident #9) out of 15 sampled residents. The facility census was 51 residents. Record Review of the facility Oxygen Therapy Policy dated 2022 showed: -Tubing, cannula, and bottle should be stored properly in an infection control manner. -Oxygen therapy was only permitted with a physician order. 1. Record Review of the Resident #32's Face Sheet showed he/she was admitted on [DATE] with diagnoses: including shortness of breath and Chronic Obstructive Pulmonary Disease (COPD-a progressive disease that is characterized by shortness of breath and difficulty breathing). Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 4/20/22, showed the resident: -Was alert and oriented with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one sampled resident (Resident #44) had a physician's order for dialysis (a process of purifying the blood of a person whose kidneys are not working normally) and monitoring the dialysis site were documented on the Physician's Order Sheet (POS); failed to ensure communication between the facility and the dialysis center was documented; failed to have care plan interventions for monitoring the resident's dialysis site out of 15 sampled residents. The facility's census was 51 residents. 1. Record review of Resident #44's Face Sheet showed he/she was admitted on [DATE] with diagnoses including chronic kidney disease, high blood pressure, history of prostate cancer, and vitamin D deficiency. Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 4/13/22, showed the resident: -Was alert and oriented with no memory loss. -Needed no…

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

Based on observation, interview and record review, the facility failed to label food containers in the 2nd floor resident storage fridge with a resident's name or the date the container was received at the facility. This practice potentially affected an unknown number of residents. The facility census was 51 residents. Record review the facility's undated admission Agreement Rules and Regulations under Exhibit C showed: - It is requested that no food or drink be brought in without consultation with the nurse. - Food if allowed by your physician, is to be stored in a container with a tight fitting lid. 1. Observation of the 2nd floor resident food storage fridge on 7/20/22 at 10:23 A.M., showed two bottles of salad dressing, one bag of chicken, one container of roast beef without names and without dates on the items. During an interview on 7/20/22 at 10:27 A.M. Licensed Practical Nurse (LPN) A said facility staff were supposed to label the items as they placed those items in the fridge and they were supposed to place a date on those items as well. During an interview on 7/20/22 at…

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