Tiffany Springs Rehabilitation & Health Care Cente

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment when facility staff did not apply Personal Protective Equipment (PPE) when they provided care and treatment for one resident (Resident #13). This affected one of 24 sampled residents (Resident #13). The facility census was 116.Review of the facility's undated, Enhanced Barrier Precautions policy, showed:-Enhanced barrier precautions (EPB) are recommended for residents with any of the following: o Wounds; o Indwelling medical devices; o High contact care activities;-High contact care activities when a gown and gloves should be worn include: o Bathing/showering; o Changing bed linens; o Changing briefs; o Assisting with toileting. 1. Review of Resident #13's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/10/25, showed:- Severe cognitive impairment;- Extensive assistance of two staff members for bed mobility, transfers, toileting and personal…

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 interviews and record review the facility failed to honor a resident's choice for a Do Not Resuscitate (DNR) advanced directive when the facility staff performed Cardiopulmonary Resuscitation (CPR), an emergency lifesaving procedure performed when the heart stops beating, and notified EMS (Emergency Medical Services) to complete all life saving measures because the facility failed to ensure the DNR had been entered into the resident's physician orders and medical record accurately. The facility census was 108.On [DATE], the Administrator was notified of the past noncompliance incident which occurred on [DATE]. On [DATE], facility administration was notified of the incident, an investigation immediately began, and corrective actions were implemented to include:- 100% audit all current residents for proper code status orders and advance directives;- All nursing staff educated on advance directive policy including: * All residents should have an advance directive order in place; * All residents advance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide necessary laboratory services for residents when they did not ensure residents needs were met with timely collection and reporting of laboratory results. This occurred when the facility failed to obtain lab testing for one resident (Resident #1) who was without his/her psychotropic medication for fourteen days when the pharmacy would not provide the medication without lab results. The facility also failed to ensure urine cultures for residents with potential urinary tract infections (UTI) were collected by the laboratory company, tested, and results received by the facility so the physician's could properly treat infections Residents #1, #2, #3, #4, #5, and #6 for signs and symptoms of UTI. The facility additionally failed to provide timely lab testing with results for two residents (Resident #2 & #5). The facility also failed to ensure sufficient laboratory testing supplies were available for staff, when the facility had no urine…

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 observations, staff interviews, and record review, the facility failed to ensure safe food handling practices, food was labeled, dated, and sealed in cold storage, and the kitchen was kept in a clean and sanitary manner. These failures had the potential to increase the prevalence and spread of foodborne illness and infection among all 116 facility residents. The facility census was 116. Findings include: Review of the facility's undated policy titled, Hand Washing & Glove Usage, revealed Employees would wash their hands before and after handling foods. Gloves were to be used whenever direct food contact was needed. Hands were to have been washed before putting them on and after removing gloves. Review of the facility's undated policy titled, Cleaning Schedule, revealed items to have been cleaned after each use included cutting boards, worktables, and counters; items to have been cleaned daily included stove top, grill, kitchen floors, microwave oven, steam table, food carts, and the exterior of large…

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 pain medication and timely interventions were provided for three of three residents (Residents (R) 107, R82, and R4) reviewed for pain management of 27 sample residents. This failure placed residents at risk of harm when pain was not assessed, monitored, with timely interventions provided. The facility census was 116. Findings include: 1. Review of R107's admission Record located under the Profile tab of the electronic medical record (EMR) revealed R107 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of the splenic flexure (the bend where the transverse colon and the descending colon meet in the upper left portion of the abdomen), liver cirrhosis, and deep vein thrombosis (DVT). Review of R107's admission Minimum Data Set (MDS) located under the MDS tab of the EMR revealed R107 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated she was cognitively intact and…

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

Based on observations, record review, interviews, and policy review, the facility failed to ensure residents who received a pureed diet of 116 total residents were served foods prepared in a pureed form to meet their needs. This failure had the potential to cause choking, aspiration [inhalation of food into the lungs], malnutrition, weight loss, or dissatisfaction with meals. The facility census was 116. Findings include: Review of the facility's policy titled, Therapeutic Diets, dated January 2017, revealed Mechanically altered diets, as well as diets modified for medical or nutritional needs, will be considered 'therapeutic' diets. Review of the facility's Order Listing Report, dated 10/04/24 and provided on paper, revealed five residents received a pureed diet. Review of the facility's Diet Extensions - Friday Week 4 menu, provided by the facility, revealed residents who received pureed foods were to receive pureed sausage links during breakfast on 10/04/24. During observation of the tray line in the kitchen on 10/04/24 beginning at 8:06 AM, revealed Cook1 served residents with 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 record review and interviews, the facility failed to ensure the physician was notified when pain medications were unavailable to be administered per physician's order for one of three residents (Resident (R) 4) reviewed for pain of 27 sample residents. This failure had the potential to contribute to uncontrolled pain and fall risk. The facility census was 116. Findings include: Review of R4's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed she was admitted to the facility on [DATE] with diagnoses including: polymyalgia rheumatica (a chronic inflammatory disorder that causes pain and stiffness in the neck, shoulders, and hips); chronic pain syndrome; rheumatoid arthritis; dementia; depression, and anxiety. Review of R4's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/15/24 and located in the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated the resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident who had a negative Preadmission Screening and Resident Review (PASARR) Level I and then later had a significant change in status with a new serious mental illness diagnosis was accurately and timely referred for a PASARR Level II for one of two residents (Resident (R) 29) reviewed for PASARRs out of 27 sample residents. This failure placed the residents at risk of qualifying for specialized services but not receiving the services due to the inaccuracy of the PASARR Level I. The facility census was 116. Findings include: During an interview on 10/03/24 at 2:00 PM, the Administrator revealed the facility had no policy on PASARR. Review of R29's admission Record, located in the resident's electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses which included acute heart failure. On 07/12/21, the resident was placed on a psychiatric hold and sent to a psychiatric…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a comprehensive patient centered care plan related to an Implantable Cardioverter Defibrillator (ICD) device one of 27 sample residents (Resident (R) 82) reviewed for care plans. The failure to update care plans to reflect the residents' needs can result in potential harm. Findings include: Review of the undated John Hopkins Medicine, titled article Living with a ICD located at https://www.hopkinsmedicine.org/health/wellness-and-prevention/living-with-a-pacemaker-or-implantable-cardioverter-defibrillator-icd revealed that there are post implant precautions that a patient has too abide by usually for life. Those precautions may include setting off some alarms in close proximity, not having a certain type of magnetic scans done, not using heat therapy, staying away from high voltage machines, careful use of cell phones and other electronic devices, just to name a few. Review of R82's undated Face Sheet located under the Profile tab 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 observations, interviews, and record reviews, the facility failed to maintain current abilities for one of one resident (Resident (R) 80) reviewed for activities of daily living (ADL) of 27 sample residents. Failure of the facility to provide proper assistance for a resident that has ADL decline could result in psychological and physical harm. The facility census was 116. Findings include: Review of R80's undated Face Sheet located under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease without dyskinesia, lymphedema, dementia moderate, with other behavioral disturbance, glaucoma, blindness, right eye, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) located under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of [DATE] revealed a Brief Interview for Mental Status (BIMS) of nine out of 15 which indicated the resident was moderately cognitively…

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 safely store an oxygen emergency tank (e-tank) for one of three (Residents (R) 272) reviewed for respiratory care of 27 sample residents. This failure placed the residents at risk of injury. The facility census was 116. Findings include: Review of the admission Record located in the Profile tab of the electronic medical record (EMR), revealed R272 was admitted to the facility on [DATE] with a diagnosis of emphysema (a lung condition that causes shortness of breath). Review of a Physician Order, dated 09/21/24 and located in the Orders tab of the EMR, revealed O2 [oxygen] at 2L [liters] as needed to keep oxygen saturation greater than 90%. During an observation on 10/02/24 at 2:59 PM, R272 was observed asleep in his wheelchair. He was connected to the oxygen concentrator via nasal cannula tubing. The e-tank was observed standing against the wall unsupported with the oxygen carrier nearby. During an interview on 10/02/24 at 3:01 PM, Minimum…

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, record review, and facility policy review, the facility failed to ensure an occlusive, peripherally inserted central catheter (PICC) line was changed every seven days, as required for one of one resident (Resident (R) 108) reviewed for intravenous (IV) antibiotic use of 27 sample residents. This failure placed the residents at risk of increased infection and complications. The facility census was 116. Findings include: Review of the facility's policy titled, Central Vascular Access Device (CVAD) Dressing Change,: dated January 2004, revealed .The catheter insertion site is a potential entry site for bacteria that may cause a catheter-related infection .Perform sterile dressing changes .upon admission .If transparent dressing is dated, clean, dry, and intact, the admission dressing change may be omitted and scheduled for 7 days from the date on the dressing label . Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R108 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure one of 27 sample residents (Resident (R) 4) medications were ordered and received for timely administration. This put residents at risk of complications from not receiving their medications. The facility census was 116. Findings include: Review of R4's Census tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE]. Review of R4's Medical Diagnosis tab of the EMR revealed she had diagnoses that included rheumatoid arthritis, chronic pain syndrome, and anxiety. Review of R4's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/15/24 and located in the MDS tab of the EMR revealed a Brief Interview for Mental Status (BIMS) of 10 out of 15 which indicated the resident was moderately cognitively impaired. R4 received scheduled pain medication and had not received any as needed medication or non-pharmaceutical pain interventions. She had pain Almost Constantly, it rarely affected her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of facility policy, the facility failed to document the death of a resident and include a physician order to release the body for one of one resident (Resident (R) 115) reviewed for death of 27 sample residents. This failure had the potential for residents to have a medical record that did not reflect care provided by the facility. The facility census was 116. Findings include: Review of a facility's policy titled, Charting and Documentation, dated 01/17, revealed .Chart all pertinent changes in the resident's condition, reaction to treatments, medications, etc., as well as routine observations .Be concise, accurate, and complete and use objective terms. Document only the facts .Death of a Resident .Pertinent information before death. (i.e., symptoms, vital signs, treatment, etc.) .Date and time of death .Name of physician notified and when notified .Name of funeral home, time notified and by whom .When and to whom the resident is released .Disposition of medications…

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 one staff maintained one sampled residents right to personal privacy for one resident (Resident #1) when Certified Nurse's Aide (CNA) A used his/her personal cell phone to record a two separate videos without the residents consent. One video showed Resident #1 lying in bed and and second video showed the resident with his/her glasses on upside down on his her face. The facility census was 119. The facility did not provide the requested policy regarding Resident Rights. The facilty did not provide the requested policy in regards to video recording of residents. Review of the Missouri Resident [NAME] of Rights, provided through the state long term are ombudsman (a person who represents the interests of residents) program included Residents have the right to privacy, to be treated with consideration, respect, and dignity, recognizing each resident ' s individuality. Review of the facilty's undated employee hand book showed in part: -Employees should: o Follow the facility's policies and work rules; o The possession 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 observations, interviews and record review, the facility failed to ensure staff provided care in a manner to preserve and enhance residents dignity when staff utilized cell phones while provided resident cares to two of eight residents (Resident #3 and #4 ), and when staff did not provide adequate supplies for residents incontinent care needs (residents #3 and #4). This affected four of eight sampled residents. The facility census was 117. Facility did not provide policy on call lights or dignity. Review of facility policy, use of cell phones and other portable communication devices, undated, showed: -The use of cellular phones, pagers, or other portable communication devices is strictly prohibited while on duty except during scheduled rest and meal periods. -Use of these devices will be restricted to the break room or outside of the community; -While on duty these devices will be stored in locker, purse/backpack, or vehicle; 1. Review of Resident #2's quarterly MDS, dated [DATE], showed: -BIMS of 14,…

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, the facility failed to provide care and treatment in accordance with professional standards of practice when oxygen tubing was not changed and dated according to physician's orders weekly (Residents #3, #5, and #7) and when daily weights were not taken on one resident (resident #5 ). This affected three of eight sampled residents. The facility census was 117. Review of oxygen administration policy, dated October 2010, showed: -Verify that there is a physician's order for the procedure of oxygen administration. -Check the tubing connected to the oxygen cylinder or concentratior to assure that it is free of kinks. -Replenish water in humidifying jar as needed; -After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: -The date and time that the procedure was performed. -Rate of oxygen flow, route. -The frequency and duration of the treatment. -Reason for PRN administration. -If resident refused the procedure, 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 they cared for residents in a dignified manner when staff failed to respond to call lights in a timely manner for residents with incontinence for five of the 21 sampled residents (Residents #85, #306, #4, #37, #42). The facility also failed to ensure staff cared for residents in a dignified manner when staff left one resident (Resident # 85) sitting in a wheelchair in only a t-shirt and an incontinent brief with his/her genitalia exposed outside of the brief, in an open hallway in view of other people and failed to change one resident's (Resident #22) bed sheet that had two brown golf ball sized stains on it that were visible from the the hall. Additionally, the facility failed to put necessary precautions in place when one resident (Resident #99) wandered into another resident of the opposite sex room (Resident #67) while that resident was using the restroom. The facility census was 104. The facility did not provide any policies…

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 #18's follow up question and report for snacks at bedtime for June, 2023 , showed the resident did not get offered a snack at bedtime on the following dates: - 6/3/23; 6/5/23; 6/6/23; 6/7/23; 6/8/23; 6/9/23; 6/10/23; 6/11/23; 6/12/23; 6/13/23; 6/14/23; 6/16/23; 6/17/23; 6/18/23; 6/20/23; 6/23/23; and 6/28/23. Review of the resident's follow up question and report for snacks at bedtime for July, 2023 , showed the resident did not get offered a snack at bedtime on the following dates: - 7/1/23; 7/2/23; 7/4/23; 7/7/23; 7/8/23; 7/12/23; 7/13/23; 7/19/23; 7/21/23; 7/22/23; 7/23/23; 7/25/23; 7/26/23; and 7/27/23. Review of Resident #18's quarterly MDS, dated [DATE] showed: - Cognitive skills severely impaired; - Independent with set up only for bed mobility, transfers, and toilet use; - Independent with eating; - Lower extremity impaired on one side; - Diagnoses included diabetes mellitus, chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing),…

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 observations and interviews, the facility failed to maintain a safe, clean and comfortable homelike environment. This affected four Residents (Residents #37, #42, #43 and #73). The facility census was 104. The facility did not provide the requested policy regarding the environment. 1. Review of Resident #37's quarterly MDS, (MDS) A federally mandated assessment instrument completed by facility staff, dated 8/15/23, showed: -Resident has moderate cognitive impairment; -Resident is independent with ADL's; (Activities of Daily Living) -Resident requires supervision for transfers; -Diagnoses included, kidney failure, diabetes mellitus and high blood pressure. A review of the resident's care plan, dated 5/25/23, showed: -Resident has an ADL self-care performance related to impaired balance; -Resident has limited physical mobility. Observation on 8/15/23, at 2:55 P.M., showed: -The resident's floor with dirt and debris; -The resident's floor had a sticky yellow substance on the floor by the bedside table.…

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 observations, interviews and record review, the facility failed to ensure staff failed to follow physician orders for three out of 21 sampled residents when they failed to follow the physician's order for oxygen therapy for one resident (Resident #89) failed to transcribe a diagnosis of dementia for one resident (Resident #99) and failed to obtain an order to obtain Resident #9's blood glucose prior to obtaining the blood glucose. The facility census was 104. The facility did not provide a policy regarding following physicians orders. Review of the facility's Oxygen Administration policy, dated 1/2017 showed: - Verify there is a physician's order for this procedure for oxygen administration; - After completing the oxygen set up or adjustment, the following information should be recorded in the resident's medical record: - Date and time the procedure was performed; - Rate of oxygen flow; 1. Review of Resident #89's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff did not provide complete perineal care which affected three of 21 sampled residents, (Resident #43, #64, and #91), failed to ensure showers were completed for Resident #43, #59 #22 and #37 and failed to ensure shaving was completed for residents, (Resident #89 #254, #22. #37 and #27). The facility census was 104. The facility did not provide a policy for peri care and did not provide a policy for showers or shaving residents. 1. Review of Resident #43's significant change in status Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/6/23 showed: - Cognitive skills intact; - Limited assistance of one staff for bed mobility; - Extensive assistance of two staff for transfers and toilet use; - Extensive assistance of one staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure staff used proper techniques to reduce the possibility of accidents or injuries when transferring three sampled residents (Resident #33, #91 and Resident #43) during the use of a mechanical lift transfer. The facility census was 104. Review of the manufacture's instructions for the Medline mechanical lift, dated 2016, showed: -Open the legs of the lift when lifting the patient; -Close the legs of the lift before moving patient ; -Open the legs of the lift for stability before lowering the patient. -When raising and lowering the resident, apply the brakes in both rear casters. 1. Review of Resident #33's significant change MDS (a federally mandated assessment tool completed by facility staff), dated 7/6/23, showed: -Severe cognitive impairment; -Extensive assistance of two staff with bed mobility, transfers, toileting and personal hygiene; -Incontinent of bowel and bladder; -Diagnoses included, dementia, arthritis and anxiety.…

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 observations, interviews and record review, the facility failed to ensure staff provided proper respiratory care when staff failed to follow physician orders for oxygen therapy for one resident (Resident #89) and failed to ensure oxygen concentrators had filters in them for one resident (Resident #306) out of 21 sampled residents. The facility census was 104. Review of the facility's Oxygen Administration policy, dated 1/2017 showed: - Verify there is a physician's order for this procedure for oxygen administration; - After completing the oxygen set up or adjustment, the following information should be recorded in the resident's medical record: - Date and time the procedure was performed; - Rate of oxygen flow; - The reason for PRN (as needed) administration. 1. Review of Resident #89's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff on 8/3/23 showed: - Cognitively impaired; - No behaviors or rejection of care; - Extensive assist with dressing, toilet use and bathing and limited assistance with transfers and personal…

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, interviews and record review, the facility failed to ensure staff administered medications with a medication error rate of less than 5%. Facility staff made six medication errors out of 25 opportunities for error which resulted in a medication error rate of 24%, which affected six out of 21 sampled residents, (Resident #5, #9, #18, #20, #37 and #88). The facility census was 104. The facility did not provide a policy for administration of medications, administration of eye drops or administration of insulin. Review of the website, www.webmd.com for administration of artificial tears showed: - Tilt the head back, look up and pull down the lower eyelid to make a pouch; - Place the dropper directly over the eye and squeeze out one or two drops as needed; - Look down and gently close your eye for one or two minutes; - Place one finger at the corner of the eye near the nose and apply gentle pressure. This will prevent the medication from draining away from the eye. 1. The facility did not provide Resident #5's physician order sheet (POS) for August 2023. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure staff provided a safe and effective medication administration system that was free of significant medication errors when staff failed to [NAME] insulin pens prior to administering insulin which affected three of 21 sampled residents, ( Resident #9, #18 and #20). The facility census was 104. The facility did not provide a policy for administration of insulin. Review of the manufacturer's guidelines for Novolog (fast acting) flexpen insulin, revised 8/22 showed, in part: - Should eat a meal within five to ten minutes after taking it; - Wipe the rubber end of the pen with an alcohol swab; - Remove the seal from the new pen needle and attach it to the end of the pen; - Turn the knob on the pen to a dose of two units; - Hold the pen with the needle straight up. Tap the side of the pen to get rid of any air bubbles; - Push the injection button until you see 0 in the dose window. You should see a drop or stream of liquid at the end 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 observations, interviews, and record reviews the facility failed to meet the nutritional choices of two resident's and failed to be prepared in advance to ensure there was enough food available for the designated menus and supplements. This effected two of 21 sampled residents (Resident #42 and #13). The facility census was 104. Review of the facility's undated policy on resident meal cards, showed: - Residents shall have a tray card on file indicating significant food preference, including any religious or cultural preferences, diet orders, food allergies, and any other nutritional needs. - Resident tray cards shall be utilized by dining services staff to identify and provide accurate meal service for the individual, while honoring their dining needs and preferences. 1. Review of Resident 13's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/13/23 showed: - Brief interview of mental status (BIMS) score of 12, which indicates…

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 received meals that were nutritive in value and palatable when residents were served cold food which affected three residents (Resident #67, #43 and #59) out of 21 sampled residents. This also had the potential to affect all residents residing in the facility. The facility census was 104. Review of the facility's undated policy for Monitoring Food Temperatures for Meal Service, showed: - Food temperatures will be monitored to ensure foods are served at palatable temperatures. Review of the facility's undated dietary aide job description form showed: - Serve meals that are palatable and appetizing in appearance; - Assist with serving meals as necessary and on a timely basis; - Set up meal trays, food carts, dining room, etc. as instructed; - Deliver food carts, trays, etc. to designated areas. 1. Review of Resident #67's admission Minimum Data Set (a federally mandated process for clinical assessment of all residents in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to ensure they provided meals to residents at regular times comparable to normal mealtimes and at the posted times which affected five of 21 sampled residents (Residents #154, #13, #75, #254, #89 ). The facility census was 104. Review of the facilities posted meal times showed: - Breakfast 8:00-9:30 A.M.; - Lunch 12:00-1:30 P.M.; - Dinner 5:00-6:30 P.M. Review of the facility's undated policy on meal time observation for food acceptance and food replacement showed: - Residents will be observed during meal times to monitor acceptance and intake of food and beverage items, and offered food replacements of similar nutritive value or other food selections the resident might enjoy; - The staff will ensure that residents consuming meals in locations outside of the dining room, such as day rooms, resident rooms or private dining rooms are monitored appropriately as needed. Review of the facility's undated meal ticket process, showed: - Tickets will…

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 kitchen in a sanitary manner when staff failed to ensure the blinds were free from dust build up and the oven was free from food particles and debris. Additionally, the facility failed to ensure food items were properly dated, labeled and expired food items were discarded. These have the potential to affect all residents residing within the facility. The facility census was 104. Review of the facility's undated Labeling and Dating Foods policy showed: - All foods stored will be properly labeled according to the following guidelines. - Food items that are unopened will be dated with the date the case was received into the facility; - Once a case of food is opened, the individual food items from the case are dated with the date the item was received into the facility; - Expiration dates on commercially prepared, dry storage food items will be followed; - Once opened, all ready to eat, potentially hazardous food will be re-dated.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to maintain an effective pest control program to prevent gnats from swarming the residents and landing on them. This affected the comfort of four sampled residents (Resident #22, #37, #42 and #43). The facility census was 104. The facility did not provide the requested policy for pest control. 1. Review of Resident #22's quarterly (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/15/23, showed: -Resident has moderate cognative impairment; -Resident is independent with ADLs; -Resident requires supervision for transfers; -Diagnoses included, kidney failure, diabetes mellitus and high blood pressure. A review of the resident's care plan, dated 5/25/23, showed: -Resident has an ADL self-care performance related to impaired balance; -Resident has limited physical mobility. Observation and interview on 8/15/23, at 12: 21 P.M., showed: -The resident said he/she had gnats in his/her room; -Multiple gnats were seen…

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.