Kirksville Manor Care Center

Based on observation, interview, and record review, the facility failed to ensure sanitary practices in the kitchen and ensure all areas of the kitchen were clean. The census was 48. Review of the facility's Sanitation policy, revised November 2022, showed the following:-All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects;-All utensils, counters, shelves and equipment are kept clean;-Service area wiping cloths are cleaned and dried or placed in a chemical sanitizing solution of appropriate concentration;-Kitchen wastes that are not disposed of by mechanical means are kept in clean, leakproof, nonabsorbent, tightly closed containers and disposed of daily. Review of the facility's Food Preparation and Service policy, revised November 2022, showed the following:-Cross-contamination can occur when harmful substances, i.e., chemical or disease-causing microorganisms are transferred to food by hands, food contact surfaces, sponges, cloth towels, or utensils that are not adequately cleaned;-Appropriate measures…

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 protect one resident (Resident #1) from physical and verbal abuse. Certified Nurse Assistant (CNA) A slapped the resident with an open hand and referred to the resident as a pedophile in the presence of the resident. The facility census was 48.On 06/30/25, the administrator was notified of the past noncompliance which occurred on 6/13/25. On 6/21/25, the administrator became aware of the staff to resident abuse allegation involving Certified Nurse Assistant (CNA) A and Resident #1. Upon discovery, the facility suspended CNA A, conducted an investigation, and notified the appropriate parties. All facility staff were educated on the facility abuse policy related to physical and verbal abuse and on the expectations for monitoring for abuse and reporting abuse. The deficiency was corrected on 6/21/25. Review of the facility's abuse policy, last reviewed on 01/31/24, showed the following:-It was the facility's policy to provide protections for the health, welfare, and rights of each resident by developing and implementing…

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.

Refer to Event ID M9W912 Based on observation and interview, the facility failed to maintain resident dignity and self determination for four residents (Resident #1, #8, #2, and #7) when staff failed to provide grooming assistance to include basic haircuts. The facility census was 51.

Refer to Event ID M9W912 Based on observation, interview, and record review, the facility failed to provide three residents (Resident #7, #8 and #2 ), of nine sampled residents, with assistance with activities of daily living (ADL) when staff failed to check for incontinence. The facility failed to ensure Resident #7's hair was groomed and pulled back out of the resident's face during meals and throughout the day. The facility also failed to ensure Resident #2 received routine showers. The facility census was 51.

Refer to Event ID M9W912 Based on observation, interview and record review, the facility failed to provide sufficient nursing staff to meet residents' needs for five sampled residents (Resident #7, #8, #2, #6, and #1). The facility failed to have adequate staffing to check and provide incontinence care to residents in a timely manner, to provide routine showers to ensure good personal hygiene, to answer call lights in a timely manner and to assist residents out of bed for meals, and ensure all residents were served meals. The facility census was 51.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to treat four residents (Resident #2 #1 #12 and #18) with dignity and respect, in a review of 18 sampled residents. Staff did not speak respectfully to residents and did not promptly respond to an incontinent resident when he/she required staff assistance. The facility census was 49. Review of the facility's policy titled Dignity, dated February 2021, showed the following: -Residents are treated with dignity and respect at all times; -Staff speak respectfully to residents at all times; -Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents by promptly responding to a resident's request for toileting assistance; -Staff are expected to treat cognitively impaired residents with dignity and sensitivity; for example: a. Addressing the underlying motives or root causes for behavior; b. Not challenging or contradicting the resident's beliefs or statements. 1. 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 observation, interview, and record review, the facility failed to provide four residents (Resident #2, #3, #16, and #8), of 18 sampled residents, with assistance with activities of daily living (ADL). Staff did not ensure Resident #2 had glasses to see when eating, left his/her hair wet after bathing, and did reposition or check for incontinence. Staff failed to check Residents #3, #16, and #8 for incontinence and reposition the residents timely. The facility census was 49. Review of the facility's Activities of Daily Living (ADL), Supporting policy, dated March 2018, showed the following: -Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: -a. Hygiene (oral care); -b. Mobility (transfer); - c. Elimination (toileting). 1. Review of Resident #2's annual MDS, dated [DATE], showed the following: -The resident had severe…

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 sufficient nursing staff to meet residents' needs for five sampled residents (Resident #7, #8, #2, #6, and #1). The facility failed to have adequate staffing to check and provide incontinence care to residents in a timely manner, to provide routine showers to ensure good personal hygiene, to answer call lights in a timely manner and to assist residents out of bed for meals, and ensure all residents were served meals. The facility census was 51. Review of the facility policy titled, Staffing, dated October 2017, showed the following: -Our facility provides sufficient numbers of staff with skill and competency necessary to provide care and services for all residents in accordance with the resident's care plan and the facility assessment; -Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services; -Staffing numbers and the skill requirements of direct care staff 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.

Based on interview and record review, the facility failed to review and update the facility wide assessment to determine what resources were necessary to care for residents competently during their day to day operations and emergencies as required. The facility census was 51. Review of the facility policy titled, Facility Assessment, dated October 2018, showed the following: -A facility assessment is conducted annually to determine and update capacity to meet the needs of and competently care for our residents during day-to-day operations. Determining our capacity to meet the needs of and care for our residents during emergencies is included in this assessment; -The team responsible for conducting and reviewing and updating the facility-wide assessment includes the administrator, a representative of the governing body, the medical director, the director of nursing (DON), the infection preventionist and also the director from environmental services, physical operations, dietary services physical operations, dietary services, social services, activity services and rehabilitative…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure proper signage on the entrance of the building, notifying visitors of Coronavirus Disease 2019 (COVID-19) outbreak in the building and failed to post transmission based precaution signage outside of one COVID-19 positive room for (Resident #5) in nine sampled residents. The facility census was 51. Review of the facility policy titled, COVID-19 Prevention, Response and Reporting, dated 5/29/24, showed the following: -It is the policy of this facility to ensure that appropriate interventions are implemented to prevent the spread of COVID-19 and promptly respond to any suspected or confirmed COVID-19 infections; -The Infection Preventionist will assess facility risk associated with COVID-19 through surveillance activities of COVID-19 infection in the community and illness present in the facility; -Threat detected-the facility will respond promptly and implement emergency and/or outbreak procedures; -The facility will establish a process to identify…

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 facility document and policy review, the facility failed to follow the prepared menu for residents who received a regular, controlled carbohydrate, renal, or pureed diet from the facility kitchen. Specifically, the facility failed to serve the correct portion size for meat, dessert, pureed entree, pureed vegetables, and pureed beans during the evening meal on 02/13/2024. This deficiency had the potential to affect all residents who received meals from the facility. The facility census was 56. Findings included: A review of a facility policy titled Menu Diet Spreadsheets/Portion Serving Communication Tool, dated 2020, revealed, Diet spreadsheets or similar meal and portion serving communication tools are available to the serving staff for reference and serving guidance. The policy further indicated, Diet spreadsheets are based on the planned menu and reflect serving portions for regular and therapeutic diet orders offered in the community. In an interview on 02/12/2024 at 10:17 AM, Resident #15 stated there was not enough food served at dinner,…

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 record review, interviews, and facility document and policy review, the facility failed to provide written beneficiary notices at least two days before the end of covered services for 3 (Resident #44, #55, and #264) of 3 residents reviewed for beneficiary notifications. The Administrator identified 17 residents who were discharged from Medicare Part A services with benefit day remaining in the last six months. The facility census was 56. Findings included: A review of a facility policy titled, Advanced Beneficiary Notices, reviewed on 01/01/2024, revealed, It is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage. The policy indicated, The current CMS [Centers for Medicare and Medicaid Services]-approved version of the forms shall be used at the time of issuance to the beneficiary (resident or representative). Contents of the form shall comply with related instructions and regulations regarding the use of the form. a. For Part A items and services, the facility shall use the Skilled Nursing Facility Advance Beneficiary Notice…

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 interviews, and facility document and policy review, the facility failed to make efforts to resolve grievances for 2 (Resident #28 and Resident #45) of 2 residents reviewed for grievances and failed to ensure information on how to file a grievance was available to residents and staff. The facility census was 56. Findings included: A review of an undated facility policy titled Grievance revealed, Our facility will help resident [sic], their representatives, other interested family members, or resident advocates file grievances when such requests are made. The policy revealed, 3. Grievances may be submitted orally or in writing. 4. The administrator [sic] has delegated the responsibility of grievance investigations to the Social Service designee. The administrator [sic] will oversee the investigation process completed by the Social Service designee. A review of Resident Council Minutes for the timeframe from July 2023 through January 2024 revealed they discussed the steps to take if someone had something come up missing. There was no documented evidence the facility had…

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

3. A review of Resident #27's admission Record revealed the facility readmitted the resident on 05/03/2022 with diagnoses that included dementia and psychotic disorder with delusions. A review of Resident #27's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/12/2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. A review of Resident #27's comprehensive care plan revealed a Focus area, initiated on 09/19/2023, that indicated the resident required treatment for behavior management. Interventions dated 09/19/2023 directed staff to review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy, and to monitor/record occurrence of for [sic] target behavior symptoms and document per facility protocol. The Focus area did not identify the resident's target behavior symptoms. An observation of Resident #27 on 02/13/2024 at 2:46 PM revealed the resident was in bed and knocking on the wall. During an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and facility policy review, the facility failed to ensure oxygen tubing and nasal cannulas were stored in accordance with the facility's policy when not in use for 3 (Residents #24, #44, and #19) of 5 sampled residents reviewed for respiratory care. The facility census was 56. Findings included: A review of a facility policy titled, Oxygen Administration reviewed on 01/01/2024, revealed, Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. The policy directed staff to e. Keep delivery devices covered in plastic bag when not in use. 1. A review of Resident #24's Face Sheet revealed the facility readmitted the resident on 03/27/2017. According to the Face Sheet, the resident had a diagnosis of chronic obstructive pulmonary disease (COPD). A review of an annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 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 observations, interviews, and facility policy review, the facility failed to store refrigerated food items in accordance with professional standards for food service safety. Specifically, the facility failed to discard milk after the use-by date and failed to label prepared sandwiches and salad with a date they were prepared or a use-by-date. This deficiency had the potential to affect all residents who received meals from the facility's kitchen. The facility census was 56. Findings included: Review of a facility policy titled, Food Storage (Dry, Refrigerated, and Frozen), with a copyright date of 2020, revealed Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. The policy specified, a. All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded. The policy further indicated, c. Discard food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing under proper…

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, record review, and facility policy review, the facility failed to ensure dignity was provided during care for one (Resident #53) of five sampled residents reviewed for dignity when facility staff failed to cover the resident when direct care was not being provided. The facility census was 56. Findings included: A review of a facility policy titled Dignity, revised in February 2021, revealed, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The policy revealed, 11. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. A review of a facility policy titled Catheter Care, Urinary, last reviewed by the facility on 01/01/2024, revealed that Steps in the Procedure included 12. Provide privacy. Cover the resident with a sheet, exposing only the perineal area. A review of Resident #53's admission Record revealed the facility admitted…

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 record review, interviews, facility policy review, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to complete a comprehensive admission Minimum Data Set (MDS) in the required timeframe for 1 (Resident #165) of 21 sampled residents reviewed for MDS assessments. The facility census was 56. Findings included: A review of a facility policy titled MDS Completion and Submission Timeframes, revised in July 2017, revealed, Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. The policy revealed, The assessment coordinator or designee is responsible for ensuring that resident assessments are submitted to CMS' QIES [Quality Improvement and Evaluation System] Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines. Further review revealed, Timeframes for completion and submission of assessments is based on the current requirements published 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 record review, interviews, facility policy review, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to complete a quarterly Minimum Data Set (MDS) in the required timeframe for 1 (Resident #1) of 21 sampled residents reviewed for MDS assessments. The facility census was 56. Findings included: A review of a facility policy titled MDS Completion and Submission Timeframes, revised in July 2017, revealed, Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. The policy revealed, The assessment coordinator or designee is responsible for ensuring that resident assessments are submitted to CMS' QIES [Quality Improvement and Evaluation System] Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines. Further review revealed, Timeframes for completion and submission 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 interviews and record review, the facility failed to provide an accurate Minimum Data Set (MDS) to assess relevant care areas for 1 (Resident #40) of 21 sampled residents reviewed for MDS assessments. The facility census was 56. Findings included: A review of Resident #40's admission Record revealed the facility admitted the resident on 01/12/2024 with a diagnosis of functional dyspepsia (indigestion). A review of Resident #40's admission MDS with an Assessment Reference Date (ARD) of 01/19/2024 revealed Resident #40 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS revealed the resident had diagnoses that included end-stage renal disease, type 2 diabetes mellitus, peripheral vascular disease, and cerebral infarction (stroke). The MDS did not indicate the resident received dialysis. A review of Resident #40's physician note dated 01/16/2024 indicated the reason for the physician's visit was for a routine adult history and physical. The note revealed under the section titled Plan, the physician documented…

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 record review, interviews, and facility policy review, the facility failed to ensure interventions were developed and implemented in an effort to prevent falls for 1 (Resident #53) of 2 sampled residents reviewed for accidents related to falls. Specifically, Resident #53, who was identified by the facility as a high fall risk, did not have interventions to prevent potential falls initiated until 02/07/2024, after the resident had sustained multiple witnessed and unwitnessed falls. The facility census was 56. Findings included: A review of a facility policy titled Falls - Clinical Protocol, revised in March 2018, revealed, 3. The staff and practitioner will review each resident's risk factors for falling and document in the medical record. The section of the policy titled, Treatment/Management specified, 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling and 2. If underlying causes cannot be readily identified 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.

Based on observation, record review, interviews, and facility document and policy review, the facility failed to ensure staff implemented proper hand hygiene practices while providing care to 1 (Resident #19) of 5 sampled residents reviewed for activities of daily living. Specifically, Certified Nursing Assistant (CNA) #21 did not wash her hands and change gloves after the provision of incontinence care prior to leaving the resident's room to retrieve supplies or prior to touching items in the resident's room, including the resident's oxygen nasal cannula and a mechanical lift. In addition, CNA #21 touched a soiled bed pad with her bare hands, and without washing her hands, went through the resident's dresser drawers. The facility census was 56. Findings included: A review of a facility policy titled, Handwashing/Hand Hygiene, revised in August 2019, revealed, 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations, b. Before and after direct contact with residents and h.…

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 treat four residents (Resident #3, #4, #5 and #6) in a review of six sampled residents, in a manner that promoted and/or enhanced the resident's quality of life by recognizing the resident's individuality, dignity and preferences. The facility failed to protect and promote Resident #4 and #6's wishes to wear pants or incontinence briefs while in bed. Resident #3 and #5 had cognitive impairment and were exposed to any passersby in the hall when their linens were pulled down exposing Resident #3's lower body and Resident #5's perineal area. The facility census was 58. Review of the facility policy titled Dignity, revised February 2021, showed the following: -Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life and feelings of self-worth and self-esteem; -Residents are treated with dignity and respect at all times; -The facility culture supports dignity 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 observation and interview, the facility failed to ensure food items were discarded when expired; failed to ensure the ovens were free of a buildup of debris; failed to ensure staff did not touch food with contaminated gloved hands; and failed to air dry serving trays and plate covers prior to meal service. The facility's certified census was 68. 1. Observations on 02/24/20 between 9:52 A.M. and 1:30 P.M., showed the following: -In refrigerator #1 (closest to the service hall entrance from the kitchen), a 1/3 gallon of whole milk with an expiration date of 01/21/20 and one unopened quart container of liquid egg whites with an expiration date of 01/19/20; -In refrigerator #2, two unsealed bags of shredded cheese, a bag of white shredded cheese with a green, mold-like substance dated 1/20, two containers of sour cream with an expiration date of 1/9/20, and a container of sour cream with an expiration date of 2/16/20; -In upright freezer #1 (located in the service entrance hallway), a buildup of food debris and ice on the bottom and a sticky substance on the door and shelves;…

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 notify three residents (Resident #56, #53, and #57) and one closed record resident (Resident #69), in a review six residents transferred to the hospital of 18 sampled residents, or their responsible party in writing of transfer to the hospital, including the reason for transfer or discharge, the effective date of transfer or discharge, the resident's appeal rights, contact information for the Ombudsman, and required advocacy groups. The facility also failed to notify the ombudsman of transfer/discharges to the hospital. The facility's certified census was 68. Review of the facility policy Transfer or Discharge Documentation, revised December 2016, showed the following: -Each resident will be permitted to remain in the facility, and not be transferred or discharged unless the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in this facility; -When a resident is transferred or discharged from the facility, the following information will be documented in the medical record:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop and implement a baseline care plan to address specific conditions, needs and risks to provide effective person centered care that met professional standards of quality of care within 48 hours of admission to the facility for four residents (Resident #43, #56, #57, and #64) in a sample of five newly admitted residents in a total sample of 18 residents. The facility failed to provide a copy of the baseline care plan to the resident or resident representative within 48 hours. The facility's certified census was 68. Review of the facility policy, Care Plans - Baseline, revised December 2016, showed the following: -Policy statement: A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission; -The interdisciplinary team will review the healthcare practitioner's orders and implement a baseline care plan to meet the resident's immediate care needs including but not limited to: initial…

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 and implement a comprehensive, person-centered care plan for seven residents (Resident #42, #43, #44, #51, #55, #56, and #64) in a sample of 18 residents in conjunction with the residents' comprehensive Minimum Data Set (MDS), a federally mandated assessment completed by facility staff. The facility's certified census was 68. Review of the facility policy, Care Plans, Comprehensive Person-Centered, revised 12/2016, showed the following: -Policy statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; -The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident; -The care planning process will: -Facilitate resident and/or representative involvement;…

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 staff failed to follow physicians orders for one resident (Resident #56) for an abductor pillow (a device to be used to avoid dislocation of the resident's hip fracture that required surgery) in a sample of 18 residents. The facility also failed to follow physician orders for tube feeding administration for one resident (Resident #49) in review of 18 sampled residents. The facility's certified census was 68. The facility did not have a policy particular to following physician orders. 1. Review of Resident #56's significant change Minimum Data Set (MDS), a federally mandated assessment, dated 2/14/20, showed the following: -admission date to the facility 9/21/19; -Diagnosis of Alzheimer's disease; -Severe cognitive impairment; -Inattention and disorganized thinking continuously; -Requires extensive assistance of two staff with bed mobility; -Dependent on staff for transfers; -Limited range of motion in one lower extremity. Review of the resident's Nurses Notes, dated January 2020, showed the following: -Fall 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 observation, interview, and record review facility staff failed to assess residents for risk of entrapment, document attempted alternatives prior to installing a bed rail, or follow the manufacturer's recommendations and specifications for installing and maintaining bed rails for 17 residents with side rails (Residents #7, #8, #33, #36, #42, #43, #44, #47, #49, #51, #52, #53, #55, #56, #57, #64, and #270), in a review of 18 sampled residents. The facility identified 40 residents in the facility had bed rails. The facility's certified census was 68. Review of the facility's policy Proper Use of Bed Rails, dated December 2007, showed the following: -To prevent resident injury and serve as an enabler for the resident; -The bed rails are considered a restraint when they are used to limit the resident's freedom of movement; -An assessment must be made to determine the resident's symptoms or reason for using bed rails; -Informed consent for the use of less restricted devices will be obtained from the 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.

Based on interview and record review the facility failed to ensure a registered nurse (RN) worked for a minimum of 35 hours as the director of nursing (DON). The facility's certified census was 68. Review of the facility's policy Director of Nursing Services, dated August 2006, showed the following: -The nursing services department is under the direct supervision of a RN. -The RN is licensed by this state, and has experience in nursing service administration, rehabilitative and geriatric nursing; -The Director of Nurses (DON) is employed full-time (40-hours per week). 1. Review of the facility's Payroll detail, dated 1/1/20-2/15/20, for the DON showed the following: -Week of 1/5/20-1/11/20: -32 hours as DON; -6.53 hours as a charge nurse; -Week of 1/12/30-1/18/20: -31.3 hours as DON; -21.72 hours as a charge nurse; -Week of 1/19/20-1/25/20: -32 hours as DON; -34.73 hours as a charge nurse; -Week of 1/26/20-2/1/20: -30.48 hours as DON; -12.47 hours as a charge nurse; -Week of 2/2/20-2/8/20: -30.28 hours as a DON; -25.7 hours as a charge nurse; -Week of 2/9/20-2/15/20: -37.17 hours 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 ensure four residents (Residents #31, #52, #56, and #57) in a review of 18 sampled residents, with orders for as needed (PRN) psychotropic medications were limited to 14 days except if an attending or prescribing physician believed that it was appropriate for the PRN order to be extended beyond 14 days, then the physician should document their rationale in the resident's medical record and indicate the duration for the PRN order. The facility also failed to ensure residents had an appropriate diagnosis for use of antipsychotic medication and hypnotic medication for one resident (Resident #56). The facility's certified census was 68. 1. Review of Resident #31's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/24/19, showed the following: -Moderately impaired cognition; -Diagnosis of anxiety disorder, major depressive disorder, and dementia; -Minimal depression; -No behavior issues 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.

Based on observation, interview and record review, facility staff failed to ensure three residents (Resident #38, #57 and #270) in a review of 18 sampled residents, were free from significant medication errors. Staff failed to prime (remove the air) from the insulin pen (prefilled pen of insulin injected under the skin used to treat diabetes dose dialed on the pen and injected through a new sterile needle attached to the pen prior to each administration), needle as instructed by the manufacturer prior to administration of the physician prescribed dose resulting in administration of less than the ordered dose of insulin. The facility's certified census was 68. 1. During an interview on 3/3/20, at 10:31 A.M., the director of nursing (DON) said the facility did not have a policy for insulin pen administration. 2. Review of the manufacturer's recommendations for the Kwikpen, dated September 2018, showed staff are directed to: -Pull off the pen cap; -Wipe the rubber stopper with an alcohol swab, screw on the needle; -Turn the dose selector to select two units; -Hold the insulin pen 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.

Based observation, interview and record review the facility failed to remove and destroy outdated medications for one resident (Resident #49) in a review of 18 sampled residents and one additional resident (Resident #65), properly label one insulin pen with a resident name and open date and failed to label seven over the counter medication bottles with open dates. The facility's certified census was 68. Review of the facility policy Administering Medications, revised December 2012, showed the following: -The expiration/beyond use date on the medication label must be checked prior to administering; -When opening a multi-dose container, the date opened shall be recorded on the container; -Insulin pens containing multiple doses of insulin are for single-resident use only; -Insulin pens will be clearly labeled with the resident's name or other identifying information. 1. Observation on 2/28/20 at 5:30 P.M. of the Hummingbird Way medication room showed an expired card of Ondansetron (anti-nausea medication) 4 milligrams (mg), 30 tabs labeled with Resident #49's name and expired 1/20/20 .…

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

Based on observation, interview, and record review, the facility failed to follow the menu for residents on a mechanical soft diet by not serving the correct amount of mechanical meat as directed by the spreadsheet menu. The facility identified six residents with diet orders for a mechanical soft diet. The facility's certified census was 68. Review of the diet spreadsheet, dated 02/24/20, showed residents on a mechanical soft diet were to receive a #8 scoop of ground deviled pork loin at the noon meal. Observation on 02/24/20 at 12:35 P.M. showed Dietary Aide F served the lunch meal. He/She did not fill the #8 scoop completely when serving the ground pork loin to all residents on a mechanical soft diet. The #8 scoop was approximately half full. During interview on 02/24/20 at 1:27 P.M., Dietary Aide F said he/she did not know why he/she did not serve a full scoop of the ground pork loin. He/She was aware he/she should serve a full scoop to the residents. During interview on 02/24/20 at 2:48 P.M., the dietary manager said she expected staff to serve the proper amount of food at meal…

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 facility failed to follow their antibiotic stewardship policy and consistently track infections and antibiotic use for four residents (Resident #51, #33, #49, and #55) in a review of 18 sampled residents. The facility's certified census was 68. Review of the facility's policy Antibiotic Stewardship, revised November 2016, showed the following: -Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program; -Purpose is to monitor the use of antibiotics for the residents; -If an antibiotic is indicated, prescribers will provide complete antibiotic orders including the following elements: a. Drug name; b. Dose; c. Frequency of administration; d. Duration of treatment (start/stop date, or number of days of therapy); e. Route of administration and; f. Indications for use. Review of the facility's policy Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcomes, revised December 2016, showed the following: -Antibiotic usage and outcome data will be collected 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 observation, interview, and record review, the facility failed to complete an inspection of bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for eight residents (Residents #56, #42, #43, #44, #47, #8, #64, and #55), of 18 sampled residents. The facility's certified census was 68. Review of the facility's policy Bed Safety, dated December 2007, showed the following: -Facility shall provide a safe sleeping environment for the resident; -To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches; a. Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; b. Review that gaps within the bed system components are worn and need to be replaced, and components meet manufacturer specifications; c. Ensure that when bed system components are worn…

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 effective call light accommodations for two residents (Resident #33 and Resident #51) in a sample of 18 residents. The facility's certified census was 68. Review of the facility's Answering the Call Light policy, revised October 2010, showed the following: -The purpose of this procedure is to respond to the resident's requests and needs; -General Guidelines: -Explain the call light to the new resident; -Demonstrate the use of the call light; -Ask the resident to return the demonstration so that you will be sure that the resident can operate the system; -Explain to the resident that a call system is also located in his/her bathroom. Demonstrate how it works; -Be sure that the call light is plugged in at all times; -When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. 1. Review of Resident #33's annual MDS, dated [DATE], showed the following: -Diagnoses included 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.