Truman Healthcare & Rehabilitation Center

Based on interview and record review, the facility staff failed to employ a qualified dietary manager for food and nutrition services with accredited education in food service management. The facility census was 104. Review of the facility's job description titled Director of Food Services, dated 2003, showed the following: -The primary purpose of the job position was to assist the dietician in planning organizing, developing and directing the overall operation of the Food Services Department in accordance with current federal, state and local standards, guidelines and regulations governing our facility, and as may be directed by the Administrator, to assure that quality nutritional services are provided on a daily basis and that the Food Services Department is maintained in a clean, safe, and sanitary manner; -Must be a graduate of an accredited course in dietetic training approved by the American Dietetic Association; -Must be registered as a Food Services Director in this state; -Must be knowledgeable of food services practices and procedures as well as the laws, regulations 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 ensure food was stored, prepared, distributed and served in a manner to protect against contamination and in accordance with standards of practice when staff failed to know the required temperature and sanitation levels and failed to regularly test the temperature and sanitation level and ensure the appropriate water temperature was reached on the dishwashing machine; staff failed maintain the stove, griddle, coffee pot, and the hand washing sink clean and free from debris; and when staff consumed food in the kitchen and dishwashing areas. The facility census was 104. 1. Review of the Food and Drug Administration (FDA) 2013 Food Code showed the the data plate provides the operator with the fundamental information needed to ensure that the machine is effectively washing, rinsing, and sanitizing equipment and utensils. The ware washing machine had been tested and the information on the data plate represented the parameters that ensured effective operation and sanitization and that need to be monitored. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 5. Review of Resident # 49's face sheet showed the following: -admission date of 12/03/19; -Diagnoses included general anxiety disorder. Review of the resident's annual MDS, dated [DATE], preferences for activities section showed the resident said it was very important to him/her to do things with groups of people, to do his/her favorite activities, and to participate in religious services. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Exhibited no behavioral symptoms; -Functional limitation in range of motion to all four extremities; -Used motorized wheelchair for mobility device; -Independent with eating; -Dependent on staff for toileting hygiene, showers, lower body dressing, and with transfers; -Required partial/moderate assistance of staff with personal hygiene; -Required substantial/maximal assistance of staff with upper body dressing, and rolling from left to right. Review of the resident's current care plan showed staff did not care plan related to the…

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

Based on observation, interview, and record review, the facility failed to ensure each resident received food and drink that was palatable, attractive and at an appetizing temperature when meals were served colder than resident preference and out of recommended service temperature range. The facility census was 104. Review of the Food and Drug Administration (FDA) 2013 Food Code showed the following: -Except during preparation, cooking, or cooling, time/temperature control for safety food shall be maintained at 41 degrees Fahrenheit (° F) or less; -Time/temperature control for safety food that is cooked to a temperature and for a time specified and received hot shall be a temperature of 135° F or above. Review of the facility's policy titled Food Preparation and Service, dated 2001, showed the following: -Food and nutrition services employees prepare, distribute, and serve food in a manner that complies with safe food handling practices; -Food Distribution means the processes involved in getting food to the resident. This may include holding foods hot on the steam table or under…

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 failed to establish and maintain an effective infection prevention and control program when the facility failed to ensure the required two step tuberculosis (TB - a communicable disease that affects the lungs characterized by fever, cough, and difficulty breathing) screening test was administered timely for seven staff members (Certified Medication Technician (CMT) F, DA G, Licensed Practical Nurse (LPN) H, Certified Nursing Assistant (CNA) I, CNA J, Registered Nurse (RN) K, and Dietary Aide (DA) E) of ten sampled staff members. The facility staff also failed to wash their hands after providing catheter (a tube that is inserted into the bladder, allowing urine to drain freely) and incontinent care for one resident (Resident #4) The facility census was 104. 1. Review of the facility's policy titled Employee Screening for Tuberculosis, revised 03/2021, showed the following: -All employees are screened for latent tuberculosis infection (LTBI) and active tuberculosis (TB) disease using tuberculin skin test (TST - a skin test used…

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 maintain a system that assured full, complete, and separate accounting of each resident's personal funds when one staff (Activity Director) had the money of one resident (Resident #49) placed in his/her own personal account for resident shopping without facility maintained record keeping regarding the transactions. The resident census was 104. Review of the facility policy titled, Management of Resident's Personal Funds, revised March 2021, showed the following: -The resident may manage his or her own personal funds; -The resident may designate a representative to manage his or her personal funds; -The resident may apply to the Social Security Administration to have a representative payee designated for purposes of federal and state benefits to which he or she may be entitled; -The resident may have the facility hold, safeguard, and manage his or her personal funds; -Should the resident elect to have the facility manage his or her personal funds, it is authorized in writing by the resident or the resident's…

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

Based on observation, interview, and record review, the facility failed to protect each resident's right to be free from abuse from staff, when a staff member continued to provide cares to a resident against the resident's wishes and refusals for one resident (Resident #17). The facility had a census of 104. Review of the facility's policy titled Abuse Prevention Program, undated, showed the following: -The facility will not tolerate verbal (any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to a resident or their families or within hearing distance, regardless of their age, ability to comprehend, or disability), sexual (non-consensual sexual contact of any type with a resident), physical (not limited to hitting, biting, kicking), or mental (humiliation, harassment, and threat of punishment or deprivation) abuse, corporal punishment, involuntary seclusion (separation of a resident ), neglect, or misappropriation of resident property (deliberate misplacement, exploitation), by employees, family members, visitors, or other…

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

Based on observation, interview, and record review the facility failed to ensure complete assessments regarding the appropriate use of a restraint before use when the facility failed to document an evaluation and consent for the use of a restraint, failed to obtain a physician order for restraint use, failed to care plan restraint use, and failed to document ongoing re-evaluations of the need for the restraint for one resident (Resident #77). The facility census was 104. Review of the facility's policy, titled Use of Restraints, revised April 2017, showed the following information: -Restraints may only be used if the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention, and a restraint is required to treat the medical symptom, protect the resident's safety, and help the resident attain the highest level of his/her physical and psychological well-being; -Prior to placing the restraint on the resident, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used 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 interview and record review, the facility failed to ensure all allegations of possible abuse were reported immediately to management and within two hours to the State Survey Agency (Department of Health and Senior Services - DHSS) when possible abuse was witnessed by staff involving two residents (Resident #32 and #57). The facility census was 104. Review of the facility's policy titled Abuse Prevention Program, undated, showed the following: -The facility will not tolerate verbal (any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to a resident or their families or within hearing distance, regardless of their age, ability to comprehend, or disability), sexual (non-consensual sexual contact of any type with a resident), physical (not limited to hitting, biting, kicking), or mental (humiliation, harassment, and threat of punishment or deprivation) abuse, corporal punishment, involuntary seclusion (separation of a resident ), neglect, or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure all allegations of possible abuse were thoroughly investigated and the investigation provided to the State Survey Agency (Department of Health and Senior Services - DHSS) within five days when possible abuse was witnessed by staff involving two residents (Resident #32 and #57). The facility census was 104. Review of the facility's policy titled Abuse Prevention Program, undated, showed the following: -The facility will not tolerate verbal (any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to a resident or their families or within hearing distance, regardless of their age, ability to comprehend, or disability), sexual (non-consensual sexual contact of any type with a resident), physical (not limited to hitting, biting, kicking), or mental (humiliation, harassment, and threat of punishment or deprivation) abuse, corporal punishment, involuntary seclusion (separation of a resident ), neglect, 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 individuals were appropriately screened prior to being placed in nursing home when the facility failed to obtain and/or maintain documentation of a level one and level two Preadmission Screening and Resident Review (PASARR) for one resident (Resident #56) . The facility census was 104. Review of the document the facility provided as their policy titled Pre-admission Screening and Annual Review (PASARR), dated 04/03/25, showed the following: -A PASARR form is required in every record. The discharge planner or facility is to be advised by the person taking the inquiry that the PASARR form must be complete prior to any new admission; -PASARR screenings are required on any resident who is placed in a state licensed only bed, who is directly transferred to your Medicaid bed from a Medicaid bed in another facility, and/or transferred from a hospital for placement in a Medicaid certified bed who occupied a Medicaid bed to hospital to Medicaid bed; -Completion of the PASARR form is the level I screening. A level II…

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 comprehensive care plans for all residents when staff failed to care plan regarding dementia, skin integrity, and multiple medications/diagnoses for two residents (Resident #92 and #61). The facility census was 104. Review of a facility policy titled Dementia-Clinical Protocol, revised November 2018, showed the following: -As part of the initial assessment, the physician will help identify individuals who have been diagnosed as having dementia or otherwise impaired cognition; -For the individual with confirmed dementia, the interdisciplinary team (IDT) will identify a resident-centered care plan to maximize remaining function of life; -For the individual with confirmed dementia, the IDT will identify a resident-centered care plan to maximize remaining function and quality of life; -Direct care staff will support the resident in initiating and completing activities and tasks of daily living; -The staff will monitor the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to identify the need for restorative therapy, failed to care plan the need for restorative therapy, and failed to provide restorative therapy services to ensure residents did not experience unavoidable reductions in range of motion and maintained maximum practical independence/range of mobility for two residents (Resident #77 and #49) who were at risk for a decline in mobility. The facility census was 104. Review of the facility's policy titled Restorative Nursing Services, revised July 2017, showed the following information: -Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services; -Residents may be started on a restorative nursing program upon admission, during the course of stay, or when discharged from rehabilitative care; -Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care; -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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure an environment remained free of accident hazards when the facility failed to document complete and accurate smoking assessments and care plan smoking for two residents (Resident # 1 and Resident #82) and when the facility when one resident (Resident #1) was found to have multiple marijuana vape pens on his/her bedside table. The facility census was 104. Review of the facility's policy titled, Smoking- Residents, revised August 2022, showed the following information: -Prior to and upon admission, residents are informed of the facility smoking policy, including designated smoking areas, and to the extent to which the facility can accommodate their smoking or non-smoking preferences; -Resident smoking status is evaluated upon admission. If a smoker, the evaluation includes current level of tobacco consumption, method of tobacco consumption, desire to quit smoking, and ability to smoke safely with or without supervision (per completed…

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 document identification and use of possible alternatives prior to the use of side rails; failed to document assessing risk versus benefits of side rail use; failed to obtain a complete informed consent for the use of side rails prior to installation; failed to care plan side rails and failed to complete ongoing assessments to ensure the side rails are safe and appropriate for use for two residents (Resident #90 and Resident #92). The facility census was 104. Review of a facility policy titled Bed Safety and Bed Rails, dated August 2022, showed the following: -The use of bed rails is prohibited unless the criteria for bed rails have been met; -Regardless of mattress type, width, length, and/or depth, the bed rail, bed frame, and mattress will leave no gap wide enough to trap a resident's face or body; -Maintenance staff routinely inspects all beds and related equipment to identify risks and problems including entrapment risks; -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 a medication regime was free from unnecessary medications when the facility staff failed to document targeted behavioral symptoms supporting the use of an antipsychotic medication and failed to document behaviors warranting the use for one resident (Resident #75) on a physician ordered anti-psychotic medication. The facility had a census of 104. Review of the facility policy titled, Psychotropic Medication Use, dated July 2022, showed the following: -Residents will not receive medications that are not clinically indicated to treat a specific condition; -A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior; -Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: Anti-psychotics, anti-depressants, anti-anxiety, and hypnotics; -Residents, families, and/or the representative are involved in the medication management…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, the facility failed to ensure a medication error rate of less than 5% when staff made three errors out of 31 opportunities resulting in an 9.68% error rate affecting two residents (Resident #76 and #45). The facility had a census of 104. Review of the facility's policy titled, Administering Medications, revised April 2019, showed the following: -The Director of Nursing (DON) supervises and directs all personnel who administer medications and/or have related functions; -Medications are administered in accordance with prescriber orders, including any required time frame; -The individual administering the medication checks the label to verify the right resident, right mediation, right dosage, right time, right documentation, and right method (route) of administration before giving the medication; -Vital signs and medication allergies should be checked prior to administration of medications, if indicated; -The individual administering the medication initials 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 record review and interview, the facility staff failed ensure all residents were free of significant medication errors when staff administered one resident's (Resident #76) high blood pressure medication against physician orders by not following perimeters included on the order. The facility was census of 104. Review of the facility's policy titled, Administering Medications, revised April 2019, showed the following: -The Director of Nursing (DON) supervises and directs all personnel who administer medications and/or have related functions; -Medications are administered in accordance with prescriber orders, including any required time frame; -The individual administering the medication checks the label to verify the right resident, right mediation, right dosage, right time, right documentation, and right method (route) of administration before giving the medication; -Vital signs and medication allergies should be checked prior to administration of medications, if indicated; -The individual administering the medication initials the resident's Medication Administration 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 protect residents from misappropriation of personal property when a staff member took two narcotic pain medication tablets from Resident #5's supply and when Resident #6, had over $700 of fraudulent purchases on his/her debit card made by a facility employee. The effected two sampled residents. The facility census was 98. Review of the facility policy titled, Abuse Prevention Program, dated 1999, showed the following: -Objective: Zero tolerance of verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, or misappropriation of resident property, by employees, family members, or other residents; -To develop and implement a system for identifying, preventing, and reporting any incident, or suspected incident, of abuse, neglect, mistreatment, or misappropriation of resident property; -Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent 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.

Based on observation, interview, and record review the facility failed to provide the highest quality of care and ensure that all residents receive treatment and care in accordance with professional standards of practice when the facility failed to document care and treatment refusals for one resident (Resident #2) with skin concerns, that ultimately led to infection. The facility census was 98. Review of the facility's undated policy, titled Wound and Skin Care Protocols, showed the following information: -The Director of Nursing (DON) will be responsible for reviewing weekly wound reports and monitoring progress/decline of any wound and assuring compliance with current standards of would care practice; -The interdisciplinary plan of care will address problems, goals, and interventions directed toward the prevention and/or treatment of impaired skin integrity/pressure injuries. Review of the facility's undated policy, titled Assessment and Documentation, showed the following information: -Assess the wound etiology, resident's overall condition, nutritional needs, pain/pain control,…

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 provide the highest quality of care when the facility failed to accurately and completely monitor and document wounds on the skin assessments and care plan pressure ulcers/injuries (skin injuries caused by prolonged pressure, friction, or shear, resulting in tissue damage) for one resident, Resident #1. The facility census was 98. Review of the facility's undated policy, titled Wound and Skin Care Protocols, showed the following information: -The Director of Nursing (DON) will be responsible for reviewing weekly wound reports and monitoring progress/decline of any wound and assuring compliance with current standards of would care practice; -All residents will be assessed by the charge nurse for risk of skin breakdown using the Braden scale ( a tool filled out by facility staff, used to assess a resident's risk of developing pressure injuries) on admission, re-admission, and with any major change in condition; -The interdisciplinary plan of care will address problems, goals, and interventions directed toward…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide pharmaceutical services to meet the needs of each resident when Certified Medication Technician (CMT) D brought narcotic pain medication tablets into the facility and placed them into the bubble pack medication card for one resident (Resident #5) and a staff member subsequently administered one dose of the medication to the resident. The facility census was 98. 1. Review of Resident #5's face sheet showed: -admitted to the facility on [DATE]; -Diagnoses of chronic pain, low back pain, anxiety disorder, major depression, and stroke. Review of the resident's care plan revised on 05/25/25, showed: -Resident is at risk for increased pain and discomfort related to a diagnosis of chronic pain; -Follow up with the resident's physician and pain management as needed; -Medication provided as prescribed; -Monitor for effectiveness of medication; -Monitor for increased pain and discomfort; -Provide diversionary activities as needed; -Therapy to screen…

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 report to the State Survey Agency (Department of Health and Senior Services - DHSS) an allegation of resident to resident sexual abuse involving two resident (Resident #1 and Resident #2) within required two hours time frame. The facility census was 91. Review of the facility's policy titled Abuse Investigation and Reporting, dated 2017, showed the following: -All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and /or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by the facility management. Findings of abuse investigations will also be reported; -All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of an unknown source and misappropriation of property, will be reported by the facility Administrator, or his/her designee, to the following…

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 employ a qualified Director of Food and Nutrition services. Failure to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, created the potential for the 93 residents to receive insufficient nutrition services. Review of the job description for the Dietary Manager position was not provided by the facility. 1. Interview during the initial tour of the facility kitchen on 07/11/23, at 10:17 AM, showed the dietary staff stated that they had been without a Dietary Manager for the past three months. During an interview on 07/13/23, at 3:45 P.M., the Administrator stated the Dietary Manager quit on 04/27/23 and that she and the Office Manager were overseeing the kitchen. The Administrator said the Dietician was employed on a consultant basis, not full time or part time. The Dietician was in the facility twice a month for six to eight hours. Neither the Administrator nor the Office Manager held a dietary manger certificate or a food service manager…

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 a safe, clean, comfortable, and homelike environment for one of four halls, the secured dementia care unit. The failure created the potential for an undesirable living situation for the 25 residents residing on the secured unit. Review of the facility Maintenance Service Policy, dated 12/09, revealed the following: -Maintenance service shall be provided to all areas of the building, grounds, and equipment; -The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times; -Functions of maintenance personnel include, but are not limited to maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines; maintaining the building in good repair and free from hazards; maintaining lighting levels that are comfortable, and assuring that exit lights are in good working order; establishing priorities in providing…

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 it was adequately equipped to allow residents to call for staff assistance through a communication system at all times when the facility did not ensure all residents had working call lights at all times. Review of the facility's policy titled, Call System/Light Policy, dated 09/22, showed the residents call system remains functional at all times. If visual communication is used, the lights remain functional. 1. Review of Resident #53's Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff) with an Assessment Reference Date (ARD) of 04/18/23, showed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident cognitively intact. The resident's DS also indicated that the resident required total assistance for incontinent care. The resident required a Hoyer lift (which allows a person to be lifted and transferred with a minimum of physical effort)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program, regarding flies, for the entire facility of 93 residents. Review of the facility's Pest Control Contract, showed the contract, dated 12/12/13, was for monthly service for pest management program designed to provide solution to the common pests found around the outside foundation environment including roaches, ants, house spider, mice/rats, millipedes, centipedes, [NAME] and pill bugs, crickets, silverfish, earwigs. There was no identification of fly treatment or service to the blue light, bug zappers. 1. Observations of the facility, by four surveyors, during the survey of 07/11/23 to 07/14/23, showed an excessive number of flies. The flies were all throughout the facility including the kitchen, dining rooms, on residents' food, persons, and equipment. Observations were made from 9:00 A.M. to 6:30 P.M. on 07/11/23; from 8:30 A.M. to 6:30 P.M. on 07/12/23; from 8:30 A.M. to 5:45 P.M. 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 record review and interview, the facility failed to ensure two of 19 residents (Resident #19 and #76), in a total sample of 42 residents, was afforded the opportunity to be included in all aspects of person-centered care planning. Review of the facility's policy titled, Resident Participation - Assessment/Care Plan, revised February 2021, showed the resident and his or her legal representative are encouraged to attend and participate in the resident's assessment and in the development of the resident's person-centered care plan. Spouses and other members of the family may participate in the resident assessment and development of the person-centered care plan with the resident's permission. 1. Review of Resident #19's Face Sheet, provided by the facility, showed the following: -admission date of 06/05/13; -Diagnoses included morbid (severe) obesity with alveolar hypoventilation (a disorder in which a person does not take enough breaths per minute), and major depressive disorder. Review of the resident's quarterly Minimum Data Set (MDS - federally mandated assessment tool…

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

Based on observation, interviews, and record reviews, the facility failed to ensure one of one sampled resident (Resident 51) had a physician's order in the medical record and was assessed and care planned for the self-administration of medications. This failure increased the risk of incomplete or inaccurate administration of medication for the resident. Review of the facility-provided policy titled Self-Administration of Medication, revised 02/21, showed the following: -Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe; -If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan; -Self-administered medications are stored in a safe and secure place, which is not accessible by other residents; -Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party; -Nursing staff review the self-administered…

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

Based on interview and record review, the facility failed to have a process in place to identify and address weight loss for one resident (Resident #25) of one resident with possible weight loss, in a sample of 42 residents. Review of the facility's policy titled, Resident Participation - Assessments/Care Plans, revised on February 2021, showed the following regarding care planning process: -Facilitates the inclusion of the resident and/or representative; -Includes an assessment of the resident's strengths and his/her needs; -Incorporates the residents personal and cultural preferences in establishing goals of care. 1. Review of the Resident #25's Face Sheet, showed the following: -admission date of 03/17/23; -Diagnoses included of chronic obstructive pulmonary disease (COPD - a group of diseases that cause airflow blockage and breathing-related problems), bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration.), and type 2 diabetes mellitus with diabetic neuropathy (nerve damage). Review of the resident's…

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

Based on observations, interviews, and record review, the facility failed to ensure one resident (Resident #30) of one resident in the sample of 43 received appropriate and timely assistance and his/her pain was controlled when he/she fell out of bed during the night shift. Review of Lippincott Nursing Procedures, eighth edition, Wolters Kluwer 2019: Pain Management pp. 570-572, showed the following: -To assess pain properly, staff need to consider the resident's description and staff's observations of the resident's physical and behavioral response; -Ask the resident to rank the pain on a scale from 0-10, with 0 denoting lack of pain and 10 denoting the worst pain possible; -Reassess and respond to the resident's pain by evaluating the response to treatment and progress toward pain management goals; -Document each step of the nursing process; -Describe the subjective information elicited from the patient, using the resident's own words; -Note the location, quality, and duration of the pain; -Record the pain-relief method selected and the resident's rating of the pain before 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 record review and interivew, the facility failed to ensure that the Facility Assessment listed all the services provided by the facility, inlcuding tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck) care. This affected one of 93 residents (Resident #64). 1. Review of Resident #64's paper medical record Face Sheet revealed showed the following: -admission date of 09/17/20; -Diagnoses included traumatic brain injury (TBI), tracheostomy, and seizures. Review of the resident's paper medical record Physician Orders for July 2023 showed the resident was to have tracheostomy changed out as needed, suction airway as needed, tracheostomy care each shift, and change tracheostomy every month on the 15th. Review of the form titled, Facility Assessment Tool, dated 03/21/23, showed the following: -The facility assessment included an evaluation of the resident populations and available facility resources and services to ensure person centered care needs are completely met; -Table 1.5 Care and Services…

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

Based on observation, interview, and record review the facility failed to protect food from possible contamination when the staff failed to complete hand hygiene or change gloves between tasks; failed to dry dishes properly and stacked dishes wet; and when staff stored dented cans on the shelf to be used in food preparation. The facility census was 92. 1. Record review of the 2013 Food Code, issued by the Food and Drug Administration, showed the following: -After cleaning and sanitizing, equipment and utensils shall be air-dried or used after adequate draining before contact with food. - Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. Observation of the kitchen on 11/18/19, at 1:43 P.M., showed seven 4-quart storage containers stacked wet on shelves in the walk-in storage space. Observation on 11/19/19, at 8:45 A.M., showed the following: -Seven 4-quart containers stacked wet in storage area; -Two cereal containers stacked wet…

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 document completion of measurements to ensure the there were no gaps that's could potentially cause injury or entrapment for ten residents (Resident #8, #19, #27, #29, #44, #47, #57, #77, #80, and #85). Staff failed to obtain physician's orders for, care plan, or obtain signed consent for the use of side rails for one resident (Resident #29). The facility census was 92. Record review of the facility's policy titled Bed Safety, dated December 2007, included the following information: -The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment; -To try to prevent death/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote…

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 assure the medication error rate was less than five percent when facility staff failed to administer medications according to the physician's orders and standards of practice resulting in 18 medication errors out of 26 opportunities. This practice affected five residents (Resident #54, #59, #74, #80, and #238). The medication error rate was 69.23%. The facility census was 92. Record review of the facility's Administering Medications Policy, dated April 2019, showed the following: -The Director of Nursing (DON) Services supervises and directs all personnel who administer medications and/or have related functions; -Medications are administered in accordance with prescriber orders, including any required time frame; -Medications are administered within one hour of their prescribed time unless otherwise specified (for example, before and after meal orders). 1. Record review of Resident # 54's face sheet (general resident information) in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assure administer antibiotics (medications to treat infections) as ordered for one resident (Resident # 29) and failed to follow-up with a physician's orders to recheck a urinalysis sample after treatment with an antibiotic for one resident (Resident # 80), both who had UTIs (urinary tract infection). Staff failed to update the care plans of two residents (Resident #29 and #80) regarding recent UTIs. The facility census was 92. Record review of the facility's Urinary Tract Infections/Bacteriuria (bacteria in the urine) - Clinical Protocol Policy, dated April 2018, showed the following: -The physician and nursing staff will review the status of individuals who are being treated for a UTI and adjust treatments accordingly. Record review of the facility's Antibiotic Stewardship Policy, dated December 2016, showed the following: -When a C&S is ordered, lab results and the current clinical situation will be communicated to the prescriber as soon 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 staff failed to properly disinfect glucometers (small hand-held devices that check blood glucose levels in residents) when collecting blood glucose (sugar that the bloodstream carries to all cells in the body to supply energy) levels on residents and failed to protect the glucometer test strips from potential contamination. This practice affected two residents (Resident #51 & #238). The facility census was 92. Record review of the Centers for Disease Control and Prevention (CDC) website showed the following information: -Blood glucometers approved for use for more than one person must be cleaned and disinfected. When blood glucose monitoring devices are shared between individuals, there is a risk of transmitting viral hepatitis (infection that causes liver inflammation and damage) and other blood borne pathogens (infectious microorganisms in human blood that can cause disease in humans). Record review of the facility's Cleaning & Disinfecting the Microdot Blood Glucose Meter, undated, showed the following information:…

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.