Grove At Kirkwood, The

Based on interview and record review, the facility failed to offer the COVID-19 vaccine for five out of five residents reviewed (Resident # 12, #13, #8, #9, and #6). The census was 91.Review of the facility's COVID Vaccine policy, dated, 7/1/25, showed:-Policy: The facility will offer the COVID vaccine to assist in mitigating the spreads of COVID-19;-Procedure: COVID-19 vaccinations shall be offered to all residents unless such immunization is medically contraindicated; Residents shall be educated on the COVID-19 vaccine they are offered, in a manner they can understand, including the information of the benefits and risks with the Centers for Disease Control and Prevention (CDC) or Food and Drug administration (FDA); Residents shall be offered the opportunity to ask questions about the risk and benefits of the vaccination; The facility shall maintain documentation of COVID-19 vaccine for all residents in the medical record. 1.Review of Resident #12's medical record showed:-Diagnoses that included heart failure and kidney disease;-No documentation that the resident was offered 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 interview and record review, the facility failed to ensure they had a system in place to track the required Certified Nurse Aide (CNA) 12 hours annual education (in-services). The facility identified 10 CNAs who worked for the facility for at least one year and all ten were sampled. Three out of 10 CNAs did not have any documented training hours, and seven out of 10 CNAs did not have the required training hours. The facility failed to ensure all CNAs were in-serviced on dementia care and abuse and neglect. In addition, there were no CNAs that received education after September 2025. The census was 91.Review of the Facility Assessment, updated and reviewed on 12/18/25, showed Staff Training/Education and Competencies:-Abuse, neglect and exploitation: training that at a minimum educates staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property. Procedures for reporting incidents of abuse and neglect, exploitation, or the misappropriation of resident property. Care/management for persons with dementia and resident abuse…

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

Based on observation, interview, and record review, the facility failed to ensure staff treated residents with dignity and in a respectful manner when staff wore earbuds while providing care for one resident (Residents #11) and one resident reported that staff frequently have earphones in (Resident #44). In addition, the facility failed to ensure all residents were served meals on reusable dishware and utensils instead of Styrofoam. The sample was 21. The facility census was 91.Review of the facility's Resident Rights policy, reviewed 7/1/25, showed the facility shall treat residents with kindness, respect, dignity, and ensure residents rights are being followed. The resident/resident representative will be informed of their rights upon admission. Review of the facility's employee handbook, undated, showed non-negotiable expectations: Use of cell phones for any purpose in any resident care areas including resident rooms, halls, nurse's stations and common areas is strictly prohibited. Cell phones are not to be heard or seen in these areas. This is the same expectation 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 on observation, interview, and record review, the facility failed to promote and facilitate the right of self-determination for every resident when staff failed to honor reasonable food requests of offering fresh fruit for one resident (Resident #13), and five of five residents representing the resident council who said they wanted fresh fruit. Fresh fruit was listed on the facility menu as an option for breakfast. The facility census was 91.Review of the facility's Resident Rights policy, reviewed 7/1/25, showed:-Policy: The facility shall treat residents with kindness, respect, dignity, and ensure resident rights are being followed. The resident/resident representative will be informed of their rights upon admission;-Resident rights included the right to:--Exercise rights;--Planning/implementing care;--Make decision/choices;--Self-determination. Review of the facility's weekly menu showed fresh fruit offered with breakfast. During an interview on 1/22/26 at 9:30 A.M., Resident #13 said fresh fruit or salads are not offered any longer on the meal trays. Only canned fruit is…

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

Based on interview and record review, the facility failed to ensure grievances raised by resident council members were acted upon in a timely manner and failed to give a rationale as to why the grievances were not acted upon. This deficient practice had the potential to affect all residents in the facility. The sample was 21. The census was 91. Review of the facility's Grievance policy, dated 7/1/25, showed:-Policy: Residents and resident representatives have the right to voice concerns or grievances, which affect their lives at this facility, without fear of discrimination or reprisal;-Procedure: Grievances may be presented to any staff member; the staff member may resolve the issue immediately. If unable to resolve immediately, follow the grievance procedure;-Social Service/Grievance Official is responsible for notifying the resident representative, and ombudsman, as appropriate, of resolution. Interdisciplinary team (IDT) members shall be responsible for notifying the resident of resolution and indicate on the grievance form. Should resolution(s) not be satisfactory and/or…

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

Based on observation and interview, the facility failed to post the federal survey results for all residents and visitors to view. The sample was 21. The census was 91. Observation of the front desk area on 1/23/26 at 10:30 A.M., showed no sign indicating the location of the facility's survey results. No survey results documentation was visible. During a group interview on 1/26/26 at 11:30 A.M., five out of five residents, whom the facility identified as alert and oriented, said they did not know where the survey results were located. During an interview on 1/29/26 at 2:07 P.M., Director of Nursing (DON) C said he/she expected the facility's survey results to be readily available to residents and family members. During an interview on 1/29/26 at 11:54 A.M., Administrator B said he/she updated the survey result binder this week and it was located at the front desk. There was no sign posted indicating where residents and family members could find the survey binder. He/She expected the survey binder to be readily available to residents and their family members.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide a safe, clean, comfortable homelike environment for three residents (Residents #78, #91 and #93). The facility also failed to keep the 200 hall shower room clean and odor free. The sample was 21. The census was 91.Review of the facility's Cleaning Resident's Rooms policy, undated, showed: -Policy: -Resident rooms at the facility are maintained and cleaned on a daily and weekly schedule; -Procedure: -Daily cleaning: -Clean the bathroom; -Dust the furniture, windowsill television and pictures; -Clean chairs, tables, and handrails with disinfection spray; -Clean door know, light switches and telephone with disinfecting spray; -Sweep and mop floors. Review of the facility's Bathroom and Shower Cleaning policy, undated, showed: -Policy: The bathrooms and showers rooms are maintained in a clan and sanitary manner and are cleaned on a daily basis; -Procedure: -Daily cleaning includes: -Emptying waste cans, -Servicing toilet paper holders;…

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 maintain an effective grievance process for residents and family members to voice grievances and prompt the facility to resolve grievances for one resident (Resident #44). In addition, five out of five residents who represent the resident council said the facility failed to properly follow up on grievances. The failure has the potential to affect all residents with grievances. The sample was 21. The census was 91.Review of the facility's Grievance and Missing Property policy, dated 7/1/25, showed:-Policy: Residents and resident representatives have the right to voice concerns or grievances, which affect their lives at the facility, without fear of discrimination or reprisal; All residents, resident representatives, and families also have the right to report missing items or property.-Purpose: To provide an opportunity for residents, resident representatives, and families to present concerns or grievances to the proper authorities at the facility and to receive a response;-Procedure: Grievances may be presented to any 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.

Based on interview and record review, the facility failed to complete all required background checks for newly hired employees prior to hiring for 10 out of 10 employees sampled. The facility failed to check the Nurse Aide (NA) Registry (checks for Federal Indicators (FI) given to individuals found guilty of abuse, neglect, and misappropriation of resident property) for seven out of 10 employees and failed to check either a criminal background check or the Family Care Safety Registry (FCSR, checks both the criminal background check (CBC) and employee disqualification list) for eight out of 10 employees. The census was 91.Review of the facility's Employee Background Checks policy, undated, showed:-The facility is committed to maintaining high quality care and service while protecting its residents from abuse, neglect, and exploitation. Accordingly, this policy sets forth the facility's process for conducting a thorough pre-hire background check of relevant individuals to ensure that relevant individuals:--Have not been found guilty of abuse, neglect, exploitation, or mistreatment 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 observation, interview and record review, the facility failed to ensure residents received care that met professional standards of quality when staff failed to obtain weights as ordered for one resident (Resident #13) and failed to administer Vitamin D as ordered for one resident (Resident #78). The sample was 21. The census was 91. 1. Review of Resident #13's quarterly Minimum Data Set (MDS), federally mandated assessment instrument completed by facility staff, dated 10/17/25, showed:-admission date 8/29/25;-Diagnoses included heart disease, kidney disease, and high blood pressure. Review of the resident's medical record, showed:-An order, dated 10/21/25, for monthly weights;-An order, dated 12/17/25, weekly weights;-No weights documented August 2025 through January 2026. During an interview on 1/23/26 at 12:25 P.M., Certified Medication Technician (CMT) W said he/she helped obtain resident weights in January 2026. He/She documented the resident's weight on a piece of paper and handed the weights to a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received appropriate activities of daily living (ADL) care to meet their needs, including showers, nail care, and assisting residents out of bed for four residents (Residents #93, Resident #12, Resident #17, and Resident #13). The sample was 21. The census was 91.Review of the facility's ADL policy, dated 7/21/25, showed the nursing staff will assist in bathing the residents to promote cleanliness and dignity. The Charge Nurse will be made aware of residents who refuse bathing. Review of the facility's Oral Hygiene policy, revised 7/1/25, showed the facility will provide oral hygiene to residents as directed by the care plan. Oral care will include cleansing the oral cavity and removing food and debris. This may reduce odors and infection and provide comfort. 1. Review of Resident #93's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/8/25,…

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 adequate supervision and assistance to prevent the risk of accidental hazards by failing to ensure staff used appropriate techniques during two transfers using a Hoyer lift (mechanical lift) (Residents #7 and #91) and during one assisted transfer without a gait belt (Resident #111). In addition, the facility failed to safely store a topical antiseptic solution by leaving it open in the room of a cognitively impaired resident (Resident #7). The sample was 21. The census was 91.Review of the facility's Total Lift Transfer policy, dated, 7/1/25 showed:-Policy:-The facility will utilize a total lift device on residents who are unable to assist with transfers;-Responsibility: Nursing employees, Nursing administration, Director of Nursing (DON);-Definitions: -Full body lift: A lifting device used to provide safety of resident/employees during transfers;-Procedure:-Position the lift near the receiving surface;-Lock the bed/chair…

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

Based on observation, interview and record review, the facility failed to have sufficient nurse staffing on a 24-hour basis to care for resident's basic needs for three sampled residents (Residents #93, #12, and #17). The facility also failed to ensure sufficient therapy staff to provide speech therapy and restorative therapy. In addition, the facility failed to ensure new staff and/or agency staff were properly oriented. This practice had the potential to affect all residents. The sample was 21. The census was 91.Review of the facility's Facility Assessment, updated 12/18/25, showed:-People involved in completing: Administrator A, Director of Nursing (DON) C, and Director of Maintenance;-Date reviewed with Quality Assurance Performance Improvement (QAPI) committee: 12/18/25;-Number of licensed beds: 117;-Average daily census: 100;-Average weekday admissions by shift: 3-4;-Average weekend admissions by shift: 0-1;-Average weekday discharges by shift: 3-4;-Average weekend discharges by shift: 0-1;-Assistance with activities of daily living monthly average:-Bed mobility sit to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 30 opportunities observed, four errors occurred, resulting in a 13.33% medication error rate (Residents #33, #34, #78, and #79). The census was 91. Review of the facility's Medication Administration Procedure Policy, undated, showed:-Purpose: To administer all medications safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms, and help in diagnosis;-Procedure:-Review the resident's medication administration record (MAR);-Read each order entirely;-Remove medication from drawer. Reach each label carefully;--When removing from drawer;-If there is any discrepancy between the MAR and the label, check the physician's order before administering the medication;-Obtain and record any vitals before as necessary prior to administration;-When giving an injection, site rotation is charted in the appropriate space on the MAR;-For medication that requires blood…

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 resident medical records were complete, accurate, and readily accessible to staff and leadership following the transition from electronic medical record (EMR) Program A to EMR Program B. The facility failed to ensure records from the prior system were fully integrated into the current system. The facility failed to ensure Administration had direct access to historical clinical information. This breakdown in record management created barriers to timely access to critical resident information and placed residents at risk for gaps in care, treatment decisions, and continuity of services. The sample was 33. The census was 66. 1. Review of Resident #94's face sheet, dated 3/26/26, showed:-admitted on [DATE];-Diagnoses included essential tremor, benign prostatic hyperplasia (BPH, enlarged prostate), bipolar disorder (mental condition that causes extreme mood swings), vascular dementia, chronic kidney disease, and pneumonia. 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.

Based on interview and record review, the facility failed to ensure the facility arbitration agreement (a private process where disputing parties agree that one or several other individuals can make a decision about the dispute after receiving evidence and hearing arguments), provided to residents upon admission, allowed the resident or his/her representative to revoke the facility's arbitration agreement within 30 days of signature. This had the potential to affect all residents admitted to the facility who signed the arbitration agreement. The facility identified 11 residents admitted in the past 30 days. The census was 91.Review of the facility's admission Agreement, showed:-Arbitration Agreement: By signing this Agreement the Resident, and/or Authorized Representative agrees with the facility that any dispute between you and us, and any dispute relating to services rendering for any condition, and any dispute arising out of diagnosis, treatment or care of the Resident including the scope of this arbitration clause and arbitrability of any claim or dispute, against whomever made…

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 offer eligible residents for pneumococcal pneumonia (pneumonia caused by bacteria) and influenza (flu) vaccine for five out of five residents sampled for immunizations (Resident #12, #13, #8, #9, and #6). The census was 91. Review of the facility's Pneumococcal Vaccine policy, dated, 7/1/25, showed:-Policy: The opportunity to receive the pneumococcal vaccine will be extended to all residents; The facility will provide pertinent information regarding the risks and benefits of receiving the vaccine;-Procedure: Residents will be offered the pneumococcal vaccine upon admission and administration of additional doses will be completed in accordance of Center for Disease Control and Prevention (CDC) guidelines; Obtain a consent; The resident and the resident's representative will be provided education per the CDC guidelines on the risks, benefits, and potential side effects of receiving the pneumococcal vaccine. Obtain a physician order; Document the immunization in the resident's medical record. Review of the facility's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of individual needs and preferences by failing to ensure call lights were in reach for two residents (Resident #95 and Resident #11) and failing to repair a shower in the 200 hall shower room timely, requiring one resident to go to another shower room that was located further from his/her room (Resident #44). The sample was 21. The census was 91. Review of the facility's Call Lights: Accessibility and Timely Response policy, dated 7/1/25, showed:-The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response;-All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light;-Each 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 maintain records and accounting for resident trust prior to September 2025. Issues were found for eight of eight residents investigated for resident trust funds (Residents #64, #65, #52, #7, #82, #92, #94, and #100). The facility failed to ensure residents had signed authorization for management of personal funds, failed to prevent resident accounts from balance negatives prior to cash withdrawals and/or debits for three residents, and failed to apply applicable interest to resident accounts. The census was 91.Based on interview and record review, the facility failed to maintain records and accounting for resident trust prior to September 2025. Issues were found for eight of eight residents investigated for resident trust funds (Residents #64, #65, #52, #7, #82, #92, #94, and #100). The facility failed to ensure residents had signed authorization for management of personal funds, failed to prevent resident accounts from balance negatives prior to cash withdrawals and/or debits for three residents, and failed to apply…

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 implement a process to ensure refundable resident deposits were identified and returned upon discharge. This deficiency had the potential to affect recently discharged residents, which included one resident (Resident #129). The resident sample was 21. The census was 91. Review of the facility's admission agreement under the previous management company, revised on 3/22/23, showed:-To reserve a room, I agree to pay in advance: -A $6,000 interest free security deposit, which is refunded within 45 days after discharge, less balances from Medicare, insurance and hospice companies. The deposit is viewed as an asset by Medicaid and must be applied toward monthly charges to quality for Medicaid. The monthly charge for room and board starts the first day a bed is held in reserve. If the resident passes away before the admission, charges will be assessed for every day the room was held in reserve. Review of the Facility's current admission agreement, received 1/23/26, showed: -Nursing Facility, Financial, and Resource Agreement:…

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 four of 21 sampled residents had a signed advanced directive or received information about their right to formulate an advanced directive. The facility also failed to ensure code status sheets were located in the facility-designated binders on the hall (Residents #17, #52, #63, and #93). The sample was 21. The census was 91. Review of the facility's Advanced Directives policy, dated 7/1/25, showed:-Policy: It is the policy of the facility to respect the resident's right of self-directed care including the right to issue advance directives on health care, to refuse/accept treatment, to make informed decisions, and/or appoint a health care agent to make decisions on behalf of the resident when the resident lacks the capacity to do so;-Upon admission, the facility will provide a resident who is medically deemed competent or resident representative, who does not have an existing advance directive, with written information 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 protect the resident's right to privacy during personal care and medical treatments when staff failed to close the door to one resident's room while performing dressing changes to their nephrostomy tubes (tube that is put into the kidney to drain urine directly from the kidney), leaving the resident exposed to the hallway during care (Resident #108). The sample was 21. The census was 91.Review of the facility's Catheter Care policy, last reviewed on 7/1/25, showed:-Policy: The facility will maintain consistent and adequate hygiene standards for residents with an catheters to maintain function and prevention of infection and complications.-Responsibility: Nursing staff, licensed nurses, nursing administration, and Director Nurses (DON);-Procedures included:--Provide privacy. Review of Resident #108's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/17/25, showed: -Cognitively intact;-Diagnoses included coronary artery disease (CAD, is a narrowing…

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

Based on interview and record review, the facility failed to ensure an allegation of alleged abuse was reported to the facility Administrator and to the Department of Health and Senior Services (DHSS) for one of 21 sampled residents (Resident #65). The census was 91. Review of the facility's Abuse Prevention policy, dated 7/1/25, showed:-Policy: The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: Facility staff, other residents, and staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual;-Procedure: The Administrator and Director of Nursing (DON) must be promptly notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the Administrator and DON must be called at home or must be paged and informed of such incident. The facility will initiate at the time of any finding of potential abuse or neglect, an investigation to determine cause and effect and provide protection…

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 allegations of abuse were investigated in a timely manner for two of 21 sampled residents (Residents #17 and #65). The census was 91. Review of the facility's Abuse Prevention policy, dated 7/1/25, showed:-Policy: The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: Facility staff, other residents, and staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual;-Procedure: The Administrator and Director of Nursing (DON) must be promptly notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the Administrator and Director of Nursing must be called at home or must be paged and informed of such incident. The facility will initiate at the time of any finding of potential abuse or neglect an investigation to determine cause and effect…

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 residents had safe discharge plans with arrangements for services/outside resources to assist in transitioning back home, or documented discharge summaries for 2 of 2 residents reviewed for discharges (Residents #124 and #1). The sample 21. The census was 91.Review of the facility's Discharge Planning Policy, dated 7/2025, showed:-An interdisciplinary summary is completed on a resident upon discharge to assure the continuum care needs of the residents are met;-Responsibility Licensed Nurse, Social Services, Therapist, Registered Dietitian/Certified Food Service, Director, and Activities Director;-Guidelines:-A physician's order must be obtained;-Upon notification or impending discharge, the interdisciplinary team (IDT) should be notified to allow staff the opportunity to educate and implement a safe discharge. Social Work (SW) should coordinate the discharge planning process;-If the resident is relocating to another nursing home/assisted living,…

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

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #123) had baseline care plan completed within the first 48-hours of admission that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The facility identified 11 newly admitted residents in the past 30 days. Of those 11, two were sampled and issues were found with one. The census was 91.Review of the facility's Comprehensive person-centered care plan policy, dated 7/1/25, showed:-Each resident will have a person-centered plan of care to identify problems, needs, strength, preferences and goals that will identify how the interdisciplinary team will provide care. -A baseline Care Plan is developed within 48 hours. Developed initial goals based upon admission orders/residents' input and is record on the Baseline Care Plan User-defined assessment (UDA);-The interdisciplinary team along with the Resident and/or Resident Representative, will identify resident problems, needs, strengths, life…

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 each resident had a comprehensive care plan completed within 7 days of completion of the resident assessment and no further out than 21 days after admission, that would address individual care for four sampled residents (Residents #1, #4, #63, and #93). The sample was 21. The census was 91.Review of the facility's Comprehensive Person-Centered Care Plan policy, dated [DATE], showed:-Each resident will have a person-centered plan of care to identify problems, needs, strength, preferences and goals that will identify how the interdisciplinary team will provide care;-The comprehensive person-centered care plan shall be fully developed within 7 days after completion of the admission Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) Assessment;-The interdisciplinary team (IDT) along with the resident and/or resident representative, will identify resident problems, needs, strengths, life history,…

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

Based on observation, interview, and record review, the facility failed to ensure residents received urinary catheter (a thin, flexible tube inserted into the body to drain urine from the bladder) care when staff failed to ensure catheter bags were positioned appropriately and failed to obtain physician orders for catheter use and care for two residents (Resident #500 and #518). The sample was 33. The census was 66. Review of the facility's Catheter Care policy, reviewed 7/1/25, showed:-Policy: Maintain consistent and adequate hygiene standards for residents with an indwelling catheter to maintain function and prevention of infection or complications. 1. Review of Resident #500's hospital discharge record, dated 3/4/26, showed:-Hospital problems included stroke, acute kidney injury, bladder cancer, urinary tract infection (UTI), wounds, and protein malnutrition;-Used a catheter for urinary output. Review of the resident's facility electronic physician order sheet (ePOS), showed:-An order, dated 3/4/26, to irrigate catheter with 100 milliliters (ml) of water every six 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.

Based on observation, interview and record review, the facility failed to ensure ostomy (medical device used to collect bodily waste) care was provided by staff and physician orders were obtained for ostomy care for one resident who had an ileostomy (surgical procedure that creates an opening (stoma) in the abdominal wall, bringing the end of the small intestine to the surface to divert waste in an external pouch) (Resident #93). The sample was 21. The census was 91. Review of the facility's Pouch Changes - Ileostomy policy, dated 7/1/25, showed:-Policy: It is the policy of this facility to ensure that residents who require colostomy services receive pouch changes consistent with professional standards of practice to minimize occupational exposure and the resident's skin exposure to fecal matter or urine;-Policy Explanation:-Ostomy care will be provided by licensed nurses under the orders of the attending physician. The order should include the type of ostomy, frequency of pouch change, and type of equipment. The nurse will allow the resident to perform as much care as possible in…

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

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #6) received appropriate gastrostomy tube (g-tube, a tube surgically inserted into the abdomen used for liquid nutrition, fluids and medications) care to avoid potential complications from the tube feeding. Facility staff failed to ensure the resident's head of bed was elevated to prevent aspiration (choking). Facility staff failed to label the tube feeding bag to ensure the tube feeding formula was not in use for an excessive amount of time to prevent spoiled formula. The facility also failed to include the resident's tube feeding care on the care plan. The sample was 21. The census was 91.Review of the facility's Tube Feeding policy, dated 7/1/25, showed:-Policy: Residents with an order for tube feeding will be assessed and monitored by a Registered Dietician to ensure nutritional needs are being met;-The policy did not address positioning of the resident or the labeling of the tube feeding bag. Review of Resident #6's admission Minimum Data Set (MDS), a federally mandated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to obtain and document informed consent for the use of side rails, to document attempted alternative approaches prior to side rail use, and to assess for the use of side rails for three residents (Residents #63, #52, and #78). The sample was 21. The census was 91. Review of the facility's Bed Rail policy, dated 7/1/25, showed:-Policy: It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. If bed rails are used, the facility ensures correct installation, use, and maintenance of the rails;-As part of the resident's comprehensive assessment, the following components will be considered when determining the resident's needs, and whether or not the use of bed rails meets those needs. The resident assessment must include an evaluation of the alternatives that were attempted prior to the installation or use…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure medication carts were free from personal items and to ensure medications were stored securely and at proper temperatures, resulting in multiple medications being discarded. In addition, the facility failed to ensure medications were appropriately labeled with open dates and/or resident names. Four medication carts were observed, and problems were found with each. The census was 91. Review of the facility's Refrigerator Temperature Monitoring Policy, dated [DATE], showed:-Purpose: To ensure the safe storage of medications, vaccines, biologicals, and other temperatures-sensitive items in compliance with Missouri Department of Health and Senior Services (DHSS), Centers for Disease Control and Prevention (CDC), Centers for Medicare & Medicaid Services (CMS) and applicable regulatory standards;-Scope: This policy applies to all refrigerators used to store medications, vaccines, laboratory specimens and patient-specific items within the…

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

Based on observation, interview and record review, the facility failed to obtain a urinalysis as ordered in a timely manner for one resident (Resident #63). The sample was 21. The census was 91. Review of the facility's Intake and Outtake Measurement policy, dated 7/1/25, showed:-Policy: Obtain an accurate record of the resident's fluid Intake and output and information will be recorded as clinically indicated;-Procedure: Charge nurse will notify physician of any abnormality or significant imbalance between intake and output. Review of the facility's laboratory test policy, dated 7/1/25, showed:-Policy: Laboratory tests are completed as ordered by the physician;-Procedure: Licensed nurse will complete lab requisitions for routine laboratory test needing to be done on the day they are due. This will be done using the information on the lab scheduling/tracking form. Licensed nurse/designee will complete the appropriate lab requisition form. This will be completed prior to each lab day, using the information on the lab scheduling/racking form. Review of Resident #63's admission 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.

Based on interview and record review, the facility failed to provide therapy services as ordered for one resident (Resident #15) who received outside physical therapy (PT) due to inconsistent therapy provided by the facility. The facility also failed to update the resident's medical record to reflect outside therapy services. The facility also failed to offer speech therapy (ST) between 9/1/25 through 1/22/26. In addition, the facility failed to have an active restorative program in accordance with resident needs, placing residents at risk for avoidable decline. The sample was 21. The census was 91. Review of the facility's Therapy Services Policy and Procedures, reviewed 7/1/25, showed:-Policy: It is the policy of the facility to provide therapy services that promote optimal resident function, independence, safety, and quality of life. Therapy services shall be:--Provided under the direction of qualified and licensed therapists;--Based on physician orders and interdisciplinary assessment;--Coordinated with nursing, social services, and dietary departments;--Documented accurately…

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

Based on observation, interview and record review, the facility failed to ensure staff completed routine inspections of bed/side rails as part of a regular maintenance program to identify possible areas of entrapment to reduce the risk of accidents for three residents with side rails (Residents #63, #52, and #78). The sample was 21. The census was 91.Review of the FDA (Federal Drug Administration) guidance, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated 3/10/06, showed:-It is suggested that facilities and manufacturers determine the level of risk for entrapment and take steps to mitigate the risk. Evaluating the dimensional limits of the gaps in hospital beds is one component of an overall assessment and mitigation strategy to reduce entrapment;-The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement;-Bed rails (commonly used synonymous terms are side rails, bed side rails, grab bars and safety rails), may be an integral part of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident with pain received pain medications as ordered by the physician. This affected one of three sampled residents (Resident #2). The census was 112.Review of the facility's Pain Management policy, dated 7/1/25, showed the following:-Policy: The facility will use a systematic approach to Pain Management; recognition, evaluation, treatment, and monitoring of pain. Individuals experiencing pain may receive pharmacological/non-pharmacological interventions to assist in pain management;-Responsibility: Nursing personnel, nursing administration, and Director of Nursing (DON);-Procedure: -Evaluate/Prevent: --Recognize when the resident is experiencing pain and identify circumstances when pain can be anticipated;--Evaluate resident for pain on admission and routine evaluations;--Manage/prevent pain, consistent with the comprehensive evaluation and plan of care, current professional standards of practice, and resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were treated with respect and dignity when Certified Nursing Assistant (CNA) B was rough and mean to a resident during peri-care (Resident #1) and told a resident he/she did not take his/her religion seriously because he/she refused to go to church service (Resident #2). CNA B had a history of complaints from residents about being rough, bossy and intimidating. The census was 91.Review of the facility's Resident Rights policy, revised 6/16/25, showed:-The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility;-The resident has the right to exercise his/her rights as a resident of the facility;-The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his/her rights and to be supported by the facility in the exercise of his/her rights;-The resident has a right to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized care plans, to address the specific needs of the residents, for three of three sampled residents in certified beds (Residents #2, #3 and #4) who were at increased risk of bleeding due to receiving anticoagulant treatment. The census was 82 with 33 in certified beds. Review of the facility's Care Plan policy, dated 2/20/25, showed it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a residents medical, nursing, mental and psychosocial needs; and all services that are identified in their comprehensive assessment and meet professional standards of quality. 1. Review of Resident #2's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/25/24, showed: -Moderate…

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 discard outdated food and label, date, and cover food. Also, facility staff performed improper infection control practices while he/she prepared puree dishes and poured the food into plates. In addition, the facility also failed to ensure kitchen equipment was clean and in working condition. These deficient practices had the potential to affect all residents who consumed food from the facility kitchen. The census was 81 with 38 residents in certified beds. 1. Observations on 5/2/24 at 9:17 A.M., 5/3/24 at 7:15 A.M., 5/4/24 at 3:04 P.M., showed the following: -Storage room: -A large can of potato salad, with a best buy date of 12/23 and 12/23/19 written on the outside of the can; -A large can of Campbells soup, with an expiration date of 3/26/23 and 12/30 written on the outside of the can; -A large can of V8 original drink mix with an expiration date of 2/13/23; -A large can of cherry pie filling with a best by date of 10/22; -Cooler: -A container of bread and butter slices without a date; -A container of kosher dill pickle…

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 reconcile the petty cash (a small amount of cash that is kept in a facility's business office to dispense to residents who have a resident trust account) on a monthly basis. The facility also failed to maintain enough funds in the resident trust to cover all residents with a resident trust for three months. The facility held funds for five residents. The census was 81 with 38 residents in certified beds. Review of the facility's Resident Rights policy, dated 1/10/24, showed: -Manage you money: You have the right to manage your own money or to choose someone you trust to do this for you; -In addition, if you deposit your money with the nursing home or ask them to hold or account for your money, you must sign a written statement saying you want them to do this; -The nursing home must allow you access to your bank accounts, cash, and other financial records; -The nursing home must have a system that ensures full accounting for your funds and cannot combine your funds with nursing home's funds; -The nursing home…

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 check for a federal indicator (identifies when an employee who has ever held a Certified Nurse Aide (CNA) certificate has ever been found to have abused, neglected, or misappropriated resident property) through the state Nurse Aide (NA) registry prior to hiring a new employee. In addition, the facility's policy failed to direct staff to check the NA registry on all employees prior to hire for three of five employees files reviewed. The census was 81 with 38 in certified beds. Review of the facility's undated Background Screening Investigation policy, showed: -Policy: Facility conducts employment background screening checks, reference checks and criminal conviction investigation checks on individuals making application for employment; -Procedure: The Staffing Coordinator, or other designee, conducts employment background checks, reference checks and criminal conviction checks on persons making application for employment with facility. Such investigations are completed prior to offer of employment; -For any individual…

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

Based on interview and record review, the facility failed to have a tracking system to ensure 10 of 10 randomly selected Certified Nurse Aides (CNAs) received the required annual 12-hour resident care training, tracked and calculated by hire date. The census was 81 with 38 residents in certified beds. Review of the facility assessment, showed: -Staff training and competencies: Abuse, neglect, exploitation and reporting; -Resident rights; -Pressure ulcer prevention; -Medication administration; -Dementia care and abuse prevention; -Care for persons with cognitive impairment; -Care for persons with mental and psychosocial disorder as well as history of trauma/Post Traumatic Stress Disorder (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event); -Implementing non-pharmacological interventions; -Falls; -Exercise and ambulation; -Range of motion; -Positioning residents; -Lifting and transfers; -Feeding assistance training; -Required in-services done yearly for all staff; -Nursing rounds/supervision done involving floor staff to…

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 acceptable standards of practice for infection prevention and control for three residents (Residents #9, #20, and #28). The facility failed to ensure the tubing for an indwelling urinary catheter (flexible tubing used to carry urine from the bladder into a drainage bag) did not drag on the floor. The facility identified two residents as having urinary catheters. Of those two, two were included in the sample and issues were identified with one (Resident #9). In addition, the facility failed to clean shared medical equipment between resident use, for two residents observed to be transferred with a mechanical lift (Residents #20 and #28). The census was 81 with 38 residents in certified beds. The sample was 12. 1. Review of the facility's Indwelling External and Suprapubic Catheter (flexible tubing inserted through the abdomen to carry urine from the bladder) policy, not dated, showed: -It is the facility's mission to allow residents comfort and dignity through the use of assistive technology such 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.

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 28 opportunities observed, 2 errors occurred, resulting in a 7.14% error rate (Resident #19). The census was 81 with 38 residents in certified beds. Review of the facility's Administering Medications policy and procedure dated, 11/17/2023: -Policy statement: medications shall be administered in a safe and timely manner, and as prescribed; -Insulin pens containing multiple doses of insulin are for single resident use only. Changing the needle does not make it safe to use insulin pens for more than one resident; -Insulin pens will be clearly labeled with the resident's name or other identifying information. Prior to administering insulin with an insulin pen, the Nurse will verify that the correct pen is used for that resident; -Policy did not address priming the pen prior to resident dose administration. Review of Manufacture How to Use Your Lantus (long-acting insulin) Pen, dated 2022: -Perform a safety test; -Dial a test dose of 2 units; -Hold pen with the…

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

Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible when staff failed to follow proper procedures during a mechanical lift transfer. An agency staff who was not trained on the facility's policies and procedures for a mechanical lift transfer, transferred a resident (Resident #1) and did not follow facility protocol, resulting in the resident falling out of a Hoyer Lift (full body mechanical lift). The sample size was three. The census was 98. Review of the facility's Hoyer Lift Transfer Procedure, revised 8/4/23, showed: -All Hoyer Lift transfers must be performed with two persons; -Open the base of the Hoyer to widest position and place base under the bed; -Make sure one of the employees is monitoring the residents head and protect the head from being bumped with the arms of the Hoyer; -Transport the resident slowly, keeping resident within the base of the Hoyer to prevent tipping; -After reaching destination, center resident and lower them by use of the down arrow on the hand…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review and staff interview, the facility failed to complete the Centers for Medicaid and Medicare Services (CMS) Form CMS-10055 Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) four of four residents (Resident (R) R151, R149, R99, and R102) reviewed for advanced beneficiary notices. Failure to provide the form could result in the resident or their responsible party not being aware of the reason services were ending or of the options and cost to continue to receive services. Findings include: Review of facility-provided undated policy titled ADVANCE BENEFICIARY NOTICE revealed To insure an Advance Beneficiary Notice (ABN) is obtained from Medicare beneficiaries when . wishes to bill for . services that may not be covered by CMS . Advance Beneficiary Notice (ABN): An ABN is a written notice given to a Medicare Beneficiary . when . believes that Medicare will not pay for some or all of the services . and wishes to bill the patient for the provided services . 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, record review and facility's policy, the facility failed to ensure, for one of one resident (Resident (R) 153), observed for blood glucose [sugar] via fingerstick that the resident had a physician's order for the task and, for one of one resident (R100) observed for intramuscular (IM) injection, the medication vial was not cleaned with an alcohol pad (prior to withdrawal of R100's medication into the syringe). The facility's deficient practice increased R153's risk of complications of adverse medication reaction and R100's risk of infection. Findings include: 1. Review of Specimen Collection for Glucose Monitoring under Chapter 52 located in book titled Fundamentals for Nursing with a copyright date of 2019 revealed Monitoring blood glucose levels is an essential component in the care of clients who have diabetes mellitus . check the client's record and prescription . Frequency and type of test vary based on the goals of management and the complexity of the client's hypoglycemic…

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 one of one sampled resident (Resident (R) 12) reviewed for limited Range of Motion (ROM) was provided treatment/services to maintain/increase range of motion of his/her bilateral hands. The facility's deficient practice increased R12's risk of range of motion decline of his/her hands and contractures. Findings include: Review of Medical Surgical Nursing copyright 2022 under chapter 2 of the book titled Lippincott CoursePoint Enhanced revealed . Each joint of the body has a normal range of motion; if the range is limited, the functions of the joint and the muscles that move the joint are impaired, and painful deformities may develop . assess, plan and intervene to prevent complications of immobility . Deformities and contractures can often be prevented by proper positioning . At times, a splint (eg.,wrist or hand) may be made by the occupational therapist to support a joint and prevent deformity .…

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, the facility failed to ensure an indwelling catheter was anchored to prevent excessive tension on the catheter and the catheter was not routinely (monthly) changed for one of one resident (Resident (R) 41) reviewed for catheter cares. The facility's deficient practice increased R41's risk of urethral tears, dislodgement of the catheter, and urinary tract infections. Findings include: Review of Management of Patient's with Urinary Disorders under tab Chapter 49 located in Lippincott Course Point Enhanced 15th edition with copy date of 2022, revealed Patients at high risk for CAUTI [catheter acquired urinary tract infection] need to be identified and monitored carefully . The catheter is an object foreign to the body and produces a reaction in the urethral mucosa with some urethral discharge . The catheter is anchored as securely as possible to prevent it from moving the urethra . Special care should be taken to ensure that any patient is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and review of facility policy, the facility failed to ensure each resident's drug regimen was reviewed at least once a month by a licensed pharmacist for two of five residents (Resident (R) 2 and R7) reviewed for unnecessary medications. Additionally, the facility failed to ensure documented rationale for the physician's response was available for R7. Findings include: Review of facility-provided undated policy titled Psychotropic Drug Policy revealed . along with Physicians and mid-level providers will use psychotropic medications appropriately working with the interdisciplinary team to ensure appropriate use, evaluation and monitoring . facility to include regular review for continued need, appropriate dosage, side effects, risk and /or benefits . Efforts to reduce dosage or discontinue of psychopharmacological medications will be ongoing, as appropriate, for the clinical situation . Psychotropic medications include: anti-anxiety/hypnotic, antipsychotic and antidepressant…

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, and review of facility policy, the facility failed to ensure behavior monitoring for psychotropic medications was in place to maintain the resident's highest practicable mental, physical, and psychosocial well-being for one resident of five residents (Resident (R) 7) reviewed for unnecessary medications. Findings include: Review of facility-provided undated policy titled Psychotropic Drug Policy revealed . along with Physicians and mid-level providers will use psychotropic medications appropriately working with the interdisciplinary team to ensure appropriate use, evaluation and monitoring . facility to include regular review for continued need, appropriate dosage, side effects, risk and /or benefits . Efforts to reduce dosage or discontinue of psychopharmacological medications will be ongoing, as appropriate, for the clinical situation . Psychotropic medications include: anti-anxiety/hypnotic, antipsychotic and antidepressant classes of drugs . Monitors psychotropic drug use…

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