Lebanon North Nursing & Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure all allegation of possible abuse were reported to the State Survey Agency (Department of Health and Senior Services - DHSS) when staff did not report an allegation of staff to resident abuse/restraint involving one resident (Resident #2) to DHSS. The facility census was 77. Review of the facility's Abuse Prevention Policy and Procedure Checklist, revised11/28/16, showed the following:-The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation, including freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms;-The intent of this requirement is for each resident to attain and maintain his/her highest practicable well-being in an environment that prohibits the use of physical restraints for discipline or convenience and prohibits the use of physical restraints to unnecessarily inhibit a 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 all allegation of possible abuse were investigated timely with steps to protect all residents implemented during the investigation when the facility failed to complete a full and documented investigation, including steps taken protect resident during the investigation, of an allegation of staff to resident abuse/restrain involving one resident (Resident #2}). The facility census was 77.Review of the facility's policy Abuse Prevention Policy and Procedure Checklist, revised11/28/16, showed the following:-The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation, including freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms;-The intent of this requirement is for each resident to attain and maintain his/her highest practicable well-being in an environment that prohibits the use of physical…

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 residents were able to remain in the facility, unless there was documented cause for transfer and proper discharge notice given, when the facility failed to allow one resident (Resident #3) to return to the facility from a hospitalization without re-evaluation by staff or written discharge notice. The facility census was 76. Review of the facility policy titled Discharge/Transfer of a Resident, undated, showed the following:-The purpose was to provide a safe departure from the facility and to provide sufficient information for aftercare of the resident;-Staff should explain discharge guidelines and reason to resident and give a copy of the Transfer and Discharge Notice as required;-The attending physician is required to write a discharge order;-Ask physician if medications are to be sent to the resident;-Complete a discharge summary and post discharge plan of care that includes a list of medications with instructions and instructions for…

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 care per standards of practice when staff failed to complete timely and complete skin assessments, failed to document accurate wound assessments, failed to obtain and update orders timely, failed to follow physician orders, failed to provide treatment as ordered, and failed to care plan wounds for two residents (Resident # 1 and # 9) of three sampled residents, with a pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device). The facility census was 77.x Review of the facility policy titled Wound Care and Treatment, undated, showed the following:-There must be a specific order for the treatment;-Documentation of the treatment should be done immediately after the treatment;-Staff should conduct on going skin assessments with weekly documentation of status;-The care plan should reflect the current status of the wound and appropriate goals 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 interview and record review, the facility failed to ensure pharmaceutical services were provided to meet the needs of one resident (Resident #4), when staff failed to notify the nurse and physician of a pattern of missed doses of medications in the morning, when staff failed to try to reapproach the resident for medication administration when the resident had refused, and when staff failed to administer medication per ordered parameters. The facility census was 70.Review of the facility policy titled Medication Administration, undated, showed the following:-Medications are given to benefit the resident's health as ordered by a physician;-Staff should administer medications and record the medication was given on the medication sheet;-Staff should document a resident's refusal of medication and note the date, time, and what occurred.(The policy did not address steps to take when a resident refused or missed a medication.) 1. Review of Resident #4's face sheet showed the following:-admission date of 10/06/21;-Diagnoses included chronic obstructive pulmonary disease (COPD -…

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 all residents received specialized rehabilitative services as needed when staff failed to provide a therapy evaluation and therapy services as care planned and ordered for one resident (Resident #4) and when staff failed to document therapy services provided or refused for one resident (Resident #5). The facility census was 76. Review of the facility policy titled Physician Orders, undated, showed the following information:-Physician orders are needed for physical therapy (PT), speech therapy (ST), and occupation therapy (OT) evaluations and therapy; -Therapy orders are to be renewed every 30 days, which may be recorded on the therapy notes.Review showed the facility did not provide a policy regarding providing and documenting physical therapy visits.1. Review of Resident #4's face sheet (brief look at resident information) showed the following:-admission date of 10/17/25;-Diagnoses included repeated falls, muscle weakness,…

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 care that reflected the resident's wishes as expressed by the residents advance directives (written instruction, such as a living will or durable power of attorney, relating to the provision of health care when the individual is incapacitated) when the facility failed to ensure one resident's (Resident #1) Do Not Resuscitate order (DNR- refers to a medical order issued by a physician or other authorized practitioner that directs healthcare providers not to administer cardiopulmonary resuscitation (CPR - a medical intervention used to restore circulatory and/or respiratory function)) was clearly and consistently documented in the resident's chart resulting in staff providing CPR when the resident wished to be a DNR. The facility census was 80. Review of the facility's policy titled Advance Directive, undated, showed the following information:-Upon admission of a resident to the facility, the social services designee (SSD) will provide written…

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

Based on interview and record review, the facility failed to ensure all residents were treated in a dignified manner, when staff withheld one resident's (Resident #1's) belongings, and would not return them timely, after the resident displayed behaviors. The facility census was 75.Review of the facility policy titled Resident's Rights, undated, showed the following:-The resident has a right to a dignified existence, self-determination, and communication with 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 and as a citizen or resident of the United States;-The resident has the right to be free of interference, coercion, discrimination and reprisal form the facility in exercising his/her rights, and be supported by the facility in the exercise of his/her rights;-The resident may retain personal possessions as space permits, unless to do so would infringe on the rights of others. 1. Review of Resident #1's face sheet (admission data) showed the following:-admission date of…

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

Based on interviews and record review, the facility failed to ensure all allegations of possible abuse were reported immediately to management and within two hours to the state licensing agency (Department of Health and Senior Services - DHSS) when staff failed to report allegations of verbal abuse and involuntary seclusion involving one resident (Resident #1) to management and DHSS in a timely fashion. The facility census was 75.Review of the facility policy titled Abuse Prohibition Protocol Manual, revised January 2017, showed the following:-Educate all staff to report to the Administrator and/or designees any alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown sources and misappropriation of resident property;-The Administrator or designee must report to the State Survey agency no later than two hours after the allegation is made if the event involved abuse or resulted in injury;-All residents have the right to be free from abuse, neglect, misappropriation of property, and exploitation;-Verbal abuse is defined as the use of oral, written…

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.

Deficiency Text Not Available

Deficiency Text Not Available

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide care per professional standards when the facility staff failed to transcribe physician orders for wound care treatment and interventions, failed to notify the physician of changes noncompliance by the resident and changes in the wounds in a timely manner, failed to document wound care, and failed to update the care plan regarding wound care interventions for one resident (Resident #1). The facility census was 76. Review of the facility's policy titled, Charting and Documentation, undated, showed the treatment documentation should include the date and time each treatment was administered, name of person administering the treatment, specific duties performed, reason(s) for a resident's refusal of the treatment, and the signature and title of the person recording the data. The facility did not provide a wound treatment/management policy or a skin assessment policy. 1. Review of the Resident #1's face sheet (brief look at resident 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.

Based on interview and record review, the facility failed to maintain complete and accurate medical records when staff failed to document contacting the physician for catheter orders, failed to document a catheter insertion attempt, failed to document a hospital transfer, and failed to document notification to the family of a change in condition for one resident (Resident # 2). The facility census was 76. Review of the facility's policy titled, Charting and Documentation, undated, showed the following: -Treatment documentation should include the date and time each treatment was administered, name of person administering the treatment, specific duties performed, and signature and title of person recording the data; -Intake and output documentation should include consistent and accurate documentation and measurement of the resident's intake and output, each shift's eight-hour total output, other pertinent observations as necessary, and signature and title of person recording the data; -Both intake and output documentation must be recorded when a resident has a catheter, IV, tube…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a complete and effective infection prevention and control program when the facility failed to ensure staff were educated on enhanced barrier precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities) and failed to ensure appropriate protective personal equipment (PPE) was readily available for staff use for one resident (Resident #1) with a catheter (flexible tubing that is used to drain urine from the bladder) and one resident (Resident #2) with a wound. The facility census was 67. Review of the Centers for Disease Control's (CDC) Implementation of Personal Protective Equipment Use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms, dated 07/12/22, showed the following: -Multidrug-Resistant Organisms (MDRO - microorganisms that are resistant to one or more classes of antimicrobial…

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 the facility promoted each resident's right to self-determination when staff failed to provide bath/showers as preferred for one resident (Resident #1) out of a sample of four residents. The facility had a census of 76. Review of the facility's policy titled, Bath (Shower), undated, showed the following: -Purpose of the policy was to maintain skin integrity, comfort and cleanliness; -Staff to encourage resident to do as much as his/her own care as possible, supervise, and assist as necessary. Review of the facility's policy titled, Bath (Bed), undated, showed the following: -Purpose of policy to maintain skin integrity, comfort and cleanliness; -Staff to encourage resident to do as much for himself/herself as possible. 1. Review of Resident #1's face sheet (admission data) showed the following: -admission date of 04/15/16; -Diagnoses included muscle weakness, anxiety disorder, and low back pain. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by…

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

Based on observation, interview, and record review, the facility failed to ensure all residents received assistance with activities of daily living (ADL -dressing, grooming, bathing, eating, and toileting) as needed when staff failed to provide timely showers for one resident (Resident #2), who resided in the dementia unit, out of a sample of four residents. The facility census was 76. Review of the facility's policy titled, Bath (Shower), undated, showed the following: -To maintain skin integrity, comfort and cleanliness; -Encourage resident to do as much as his/her own care as possible, supervise, and assist as necessary. 1. Review of Resident #2's face sheet (admission data) showed the following information: -admission date of 06/17/22' -Diagnoses included vascular dementia, depression, and pain. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated, 12/19/24, showed the following information: -Moderately impaired cognitive skills; -Required substantial/maximal assistance with showering/bathing;…

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 report an allegation of abuse to the State Survey Agency (Department of Health and Senior Services - DHSS) within the required time two hour frame when one resident (Resident #1), out of six sampled residents, made an allegation of sexual abuse to facility staff. The facility census was 55. Review of the facility's policy titled Reporting, dated 11/28/16, showed the following: -It is the policy of this facility that each resident will be free from abuse. Abuse can include verbal, mental, sexual, or physical abuse, misappropriation of resident property and exploitation, corporal punishment or involuntary seclusion; -The Nursing Home Administrator or designee will report abuse to the state agency per State and Federal requirements; -All allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown sources, and misappropriation of resident will be reported immediately but no later than the following timeframes. If abuse is alleged or the allegation results in serious bodily injury, the allegation must 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.

Based on interview and record review, the facility failed to provide wound care as ordered and in accordance with standards of practice when staff did not document reasons for wound care not being provided or attempts to re-approach or educate the resident regarding needed wound care for one resident (Resident #49) out of a sample of five residents. The facility census was 66. Review of the facility's policy, titled Physician Orders, undated, showed treatment orders specify what is to be done, location and frequency, and duration of the treatment. Review of the facility's policy, titled Wound Care and Treatment, undated, showed the following: -It is the purpose of the facility to prevent and treat all wounds; -Documentation of the treatment should be done immediately after the treatment. (The policy did not address documentation of resident refusals of treatment or treatment when residents are asleep) 1. Review of Resident #49's face sheet showed the following: -admission date of 03/01/24; -Diagnoses included acute respiratory failure (difficulty breathing), muscle weakness, fistula…

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 a registered nurse (RN) was on duty for eight consecutive hours on 05/05/24 and 05/18/24. Review showed the facility did provide a policy regarding RN coverage. 1. Review of the facility's Nurse Monthly Staff Schedule, dated May 2024, showed the following: -There was not an RN scheduled on 05/05/24 and 05/18/24. Review of the Administrator's (who is also an RN) and the Directory of Nursing's (DON) Timecard, dated 01/01/24 to 05/22/24, and review of RN1's Time Card, dated 01/01/24 to 05/21/24, confirmed that no RN worked on 05/05/24 and 05/18/24. During an interview on 05/21/24, at 4:01 P.M., the DON said the facility knew they were out of compliance with this requirement. The DON said the facility employs one RN. During an interview on 05/23/24, at 5:53 P.M., the Minimum Data Assessment Coordinator (MDSC) said she assists with staff scheduling and when the facility advertises, they do not receive applications. During an interview on 05/23/24, at 5:53 P.M., the Administrator confirmed there was no RN coverage for…

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

Based on observation, record review, and interviews, the facility failed to provide an ongoing group or individual activity program to support the physical, mental, and psychosocial well-being of three residents (Resident #15, #32, and #44) of five sampled residents residing on the secure unit. Review of the Facility Activity/Recreational Therapy Manual, dated March 2012, provided by the Administrator, showed the following: -The policy and procedures for the activity program was to plan, organize, and carry out a program of activities to meet individual psychological, social and spiritual needs of each resident; -Individualized program of activity would be implemented for residents unable to participate in or attend activities; -Progress notes should include a resident's response to an activity as active or passive, and the extent of the activity involvement for each resident; -Resident participation should be documented on a daily basis to monitor a resident's attendance, participation, refusal and level of participation that would be utilized to determine changes that may or may…

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

Based on observation, record review, and interview, the facility failed to ensure a Notice of Medicare Non-Coverage (NOMNOC) notification was provided timely for two residents (Residents #49 and #270) of three residents reviewed for beneficiary notification out of a total sample of 24 residents. 1. Review of Resident #49's admission Record, located in the Profile tab of the electronic medical record (EMR), showed the following: -admission date of 03/01/24; -Diagnoses included foot drop right foot. Review of the resident's SNF Beneficiary Notification Review, form showed Medicare Part A skilled services start date was 03/01/24 and the last day covered was 03/16/24. Review of the resident's medical record showed staff did not have documentation of a NOMNOC or ABN (Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage - Form if the beneficiary intends to continue services and the SNF believes the services may not be covered under Medicare. It is the facility ' s responsibility to inform the beneficiary about potential non-coverage and the option to continue services 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, record review, and interview, the facility failed to ensure a significant change assessment was completed within 14 days for one resident (Resident #33) out of two residents reviewed for hospice out of a total sample of 24 residents. Review of the Resident Assessment Instrument (RAI) Manual, dated October 2023, showed the following: -A Significant Change in Status Assessments (SCSA) is required to be performed when a terminally ill resident enrolls in a hospice program or changes hospice providers and remains a resident at the nursing home; -The ARD must be within 14 days from the effective date of the hospice election. 1. Review of Resident #33's admission Record, located in the Profile tab of the electronic medical record (EMR), showed the following: -admission date of 08/18/23; -Diagnoses included unspecified dementia. Review of the resident's Physician Orders, located under the Orders tab in the EMR, dated 08/29/23, showed the resident was admitted to hospice services. Review of the resident's quarterly 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.

Based on record review and interviews, the facility failed to refer a Pre-admission Screening and Resident Review (PASSAR) resident who had a negative Level I Preadmission Screen, who was later identified with a new mental disorder diagnosis to the appropriate state designated authority for a Level II PASARR evaluation and determination for one resident (Resident #61) of five residents reviewed for PASARR of 24 sample residents. This failure had the potential to negatively affect the resident's mental and psychosocial well-being. Review showed the facility did not provide a policy related to PASARR screening/process. 1. Review of Resident #61's Face Sheet, undated, located in the electronic medical record (EMR) under the profile tab showed the resident was diagnosed with anxiety disorder on 11/22/23, major depressive disorder on 07/11/24, and with bipolar disorder on 07/23/24. Review of the resident's significant change Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), with an Assessment Reference Date (ARD) of 02/16/24, showed 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, record review, and interview, the facility failed to ensure there was ongoing pre and post dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly)communication for a resident receiving dialysis three times a week for one resident (Resident #8) out of one resident reviewed for dialysis out of a total sample of 24 residents. Review of the facility's policy titled, Dialysis, Care of a Resident Receiving Dialysis, undated, showed the following: -All care concerns within the last 24 hours will be addressed, including the last medications given and facility contact person; -The dialysis unit will complete the lower portion of the report to include weight prior to and after dialysis, any labs completed, medication given, follow up information, and any new physician's orders; -The lower portion will be signed by the dialysis nurse and returned to the facility. 1. Review of Resident #8's admission Record, located in the Profile tab of the electronic medical record (EMR), showed the following: -admission date…

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

Based on observation, record review, and interview, the facility failed to ensure there was documented clinical rationale for as needed (PRN) psychotropic medication orders longer than 14 days for two residents (Resident #6 and #32) of the five residents reviewed for unnecessary medications. 1. Review of Resident #6's admission Record, located in the Profile tab of the electronic medical record (EMR), showed the following: -admission date of 08/18/19; -Diagnoses included mood disorder and anxiety disorder. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff) under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 03/14/24, showed the following: -No cognitive impairment; -Prescribed psychotropic medication. Review of of the resident's Care Plan, located under the Care Plan tab of the EMR, dated 03/14/24, showed psychotropic drug use with intervention in place to complete medication evaluations as ordered. Review of of the resident's Physician Orders, located under the Orders tab in the EMR,…

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 a comprehensive care plan for one resident (Resident #1) that addressed the resident's bathing preference and potential behaviors when showers were given by staff. The facility with a census of 64. Review of the facility policy titled, Care Plan Comprehensive, undated, showed the following: -The interdisciplinary care plan team, with input from the resident and family, will develop and maintain a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain; -Assessment of each resident is an ongoing process and the care plan will be revised as changes occur in the resident's condition; -Assessing and planning for care to meet the resident's medical, nursing, mental and psychosocial needs; -Involving direct care staff with the care planning process relating to the resident's expected outcomes; -The interdisciplinary care plan team is responsible for the periodic review and updating of care plans when a significant change in 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 record review and interview, the facility staff failed ensure a pain management program was provided to all resident per standards of practice, when staff failed to reorder pain medication timely and failed to administer another pain medication per orders for one resident (Resident #1). A sample of fourteen residents was selected for review in facility with a census of 67. Review of the facility's policy titled Physician Orders, undated, showed the following information: -Current lists of orders must be maintained in the clinical record on each resident to avoid confusion and errors; -Physician orders must be reviewed and renewed; -Medication orders specify the type, route, dosage, frequency, and strength of the medication ordered. Review of the facility's policy titled Medication Administration, undated, showed medications are given to benefit a resident's health as ordered by the physician. Review of the facility's policy titled Medications, Errors, and Drug Reactions, undated, showed staff to report all medication errors and adverse drug reactions immediately 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 interviews and record review, the facility failed to ensure an allegation of possible abuse was reported immediately to management and within two hours to the State Survey Agency (Department of Health and Senior Services - DHSS) when staff received allegation of possible abuse involving one resident (Resident #1). The facility census was 69. Review of the facility's policy titled Abuse Prevention Policy and Procedure Checklist, dated 11/28/16, showed the following: -The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation, including freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms; -In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than two hours after the allegation is 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 interviews and record reviews, the facility failed to ensure that an allegation of possible abuse was thoroughly and timely investigated, and steps were immediately taken to protect all residents, when a staff member received an allegation of possible abuse regarding one staff member (Certified Nurse Aide (CNA) B and one resident (Resident #1). The facility census was 69. Review of the facility's policy titled Abuse Prevention Policy and Procedure Checklist, dated 11/28/16, showed the following: -The facility must take the following actions in response to an alleged violation of abuse, neglect, exploitation or mistreatment: -Thoroughly investigate the alleged violation; -Prevent further abuse, neglect, exploitation and mistreatment from occurring while the investigation is in progress;and -Take appropriate corrective action, as a result of investigation findings. -The facility must have evidence of a thorough investigation including resident statements, witness statements, staff statements, environmental review, resident physical assessment, including a timeline of events;…

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 the resident or resident representative with a Notice of Medicare Provider Non-Coverage (NOMNC) when all covered Medicare services were ending for three residents (Resident #132, #133, and #134), who discharged home from the facility after Medicare services ended. The facility census was 81. Record review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C-09-20), dated 1/9/09, showed the following information: -The Notice of Medicare Provider Non-Coverage (NOMNC, form CMS-10123) is issued when all covered Medicare services end for coverage reasons; -If the Skilled Nursing Facility (SNF) believes on admission or during a resident's stay that Medicare will not pay for skilled nursing or specialized rehabilitative services and the provider believes that an otherwise covered item or service may be denied as not reasonable or necessary, the facility must inform the resident or his/her legal representative in writing why these specific services may not be covered and the beneficiary'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 record review and interview, the facility failed to complete criminal background checks, employee disqualification list (EDL- a list maintained of individual unable to work in long-term care facilities in Missouri) checks, and/or Nurse Aide (NA) registry (a registry that indicated a list of individuals who had a previous incident involving abuse, neglect, or misappropriation of property that would prevent the employee from working in a certified long-term care facility) checks for a federal indicator prior to starting employment and continued resident contact for four staff. The facility census was 81. Record review of the facility's protocol titled, Abuse Prohibition, dated November 2016, showed the following: -It is the purpose of this facility to prohibit mistreatment, neglect, abuse, misappropriation of resident's property, and exploitation of any resident; -To assure that everything possible is being done to prevent abuse, the facility has implemented screening of potential employees; -The facility must not hire an employee who was found guilty of abuse, neglect,…

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 interview, the facility failed ensure care was completed in accordance with standards of practice when staff failed to complete ordered labs for three residents (Resident #11, #15, and #50) and facility failed to follow physician's orders for thickened liquids for one resident (Resident #64) with a diagnosis of dysphagia (difficulty swallowing). The facility census was 81. 1. Record review of Resident #15's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 1/26/19; -Diagnoses included adult failure to thrive (a general decline in mental and physical health due to complex reasons), chronic obstructive pulmonary disease (COPD - a type of lung disease which makes it difficult to breathe, even when at rest), chronic pain, and anxiety; -Receiving hospice services since 2/22/22. Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument, completed by facility…

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 maintain documentation of Quality Assessment and Assurance (QAA) Committee meetings, staff that attended the meeting, and the issues addressed. The facility census was 81. Record review showed the facility did not provide a policy regarding their QAA committee. 1. Record review of the facility's QAA/QAPI (Quality Assurance/Performance Improvement) Manual, showed the following: -QAPI meeting minutes, dated 05/04/22, with the subject identified as Minimum Data Set (MDS - federally mandated assessment tool completed by the facility staff) completion/compliance. Signatures of staff attending the meeting did not include the medical director (a required member of the QAA committee); -Staff did not document any other dates of QAA/QAPI committee meeting. During interviews on 08/22/22, at 8:53 A.M., on 8/23/22, at 10:37 A.M., and on 8/25/22, at 1:56 P.M., the Administrator the following: -The Director of Nursing (DON) was responsible for QAA/QAPI and had all the documentation on the QAA/QAPI; -The Administrator said she could only…

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 follow their infection control policy when staff failed to complete the first step of employee tuberculosis (TB - a potentially serious infectious bacterial disease that mainly affects the lungs) screening tests prior to resident contact for three staff and failed to complete the second step of the the employee TB screening test for three staff members. The facility census was 81. Record review of the facility's policy, Tuberculosis Control, undated, showed the following information: -Provide a tuberculin skin test (Mantoux - five tuberculin units of purified protein derivative (PPD)) to all employees during the pre-employment procedures, unless a previous reaction greater than 10 mm (millimeters) is documented. If the initial skin test result is 0 to 9 mm, a second test should be given at least one week later and no more than three weeks after the first test; -All employees will be screened for TB; -All PPDs will be documented on the Employee Immunization record including new hires and annual administration. After the PPD…

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 complete a baseline care plan for one resident (Resident #81) in a facility with a census of 81. 1. Record review of the resident's face sheet showed the following: -admission date of 7/25/22; -Diagnoses included anemia (low iron levels in the blood), type 2 diabetes mellitus (group of diseases that affect how the body uses blood sugar (glucose)), chronic kidney disease, schizophrenia (a disorder affecting a person's ability to think, clear, and behave clearly), major depressive disorder, and anxiety disorder. Record review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 7/29/22, showed the following: -admitted on [DATE]; -Cognitively intact; -Independent with most activities of daily living, except required supervision with meals and showers; -Resident had an indwelling urinary catheter (a sterile tube inserted into the bladder to drain urine) and took a diuretic (water…

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 complete a comprehensive care plan for one resident (Resident #81) in a facility with a census of 81. Record review of the facility policy titled, Care Plan Comprehensive, showed the following: -The interdisciplinary care plan team, with input from the resident and family, will develop and maintain a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain; -The resident's comprehensive care plan is developed within seven days of the completion of the resident's comprehensive assessment. 1. Record review of the resident's face sheet showed the following: -admission date of 7/25/22; -Diagnoses included anemia (low iron levels in the blood), type 2 diabetes mellitus (group of diseases that affect how the body uses blood sugar (glucose)), chronic kidney disease, schizophrenia (a disorder affecting a person's ability to think, clear, and behave clearly), major depressive disorder, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to take steps to ensure one resident's (Resident #27's) code status change to do not resuscitate (DNR - a medical order issued by a physician or other authorized non-physician practitioner that directs healthcare providers not to administer CPR (any medical intervention used to restore circulatory and/or respiratory function that has ceased) in the event of cardiac or respiratory arrest) was reviewed and signed by the physician and family in a timely fashion. The facility census was 81. Record review of the facility policy titled, Advance Directive, undated, showed the following: -The facility will respect the advance directives in accordance with state law; -Upon admission of a resident to the facility, the social services designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right 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 provide one resident (Resident # 34) with restorative therapy as recommended by the physical and occupational therapists and as ordered by the physician. The facility census was 81. Record review of the facility's restorative nursing (RNA) program policy,undated, showed the following: -The restorative nursing program is an integral part of maximizing the daily restorative care process for the residents; -The RNA program is a part of the logical step-down process in resident care; -A pro-active approach is necessary to prevent future negative outcomes; -It is the purpose of this facility to see that each resident receives and the facility provides the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well being in accordance with the comprehensive assessment and plan or care; -It is the entire staff's responsibility to prevent deterioration and further functional loss of each resident 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.

Based on observation, interview, and record review, the facility failed to ensure a clean and homelike environment when staff failed to clean bathroom and resident room floors. The facility census was 101. 1. Record review of the resident council minutes, dated 5/31/19, 6/25/19, and 7/31/19, showed the following information: -On 5/31/19, resident council minutes showed the following concerns: extra attention in the bathroom needed. Staff mop and potentially leave a residue. The facility response showed for staff to check the residents' rooms periodically for this occurrence and relay this to the vendors in case it is a chemical reaction; -On 6/25/19, resident council minutes showed the following concerns: Staff are not sweeping or mopping under the residents' beds and the floor. The facility response showed housekeeping inservice and all staff to assist in ensuring the rooms are clean. Housekeeping supervisor to make rounds daily; -On 7/31/19, resident council minutes showed the following concerns: housekeeping staff are not cleaning under the residents' beds, bathroom odors 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 keep non-food contact surfaces in the kitchen clean and sanitary. The facility census was 101. Record review of the 2013 Missouri Food Code showed the following information: -Physical facilities shall be cleaned as often as necessary to keep them clean; -Nonfood-contact surfaces of equipment shall be kept free of any accumulations of dust, dirt, food residue, and other debris. Record review of the facility's policy from the Nutrition and Dining Services Manual, dated April 8, 2011, for cleaning the floors, cleaning refrigerators and walls, cleaning dishwashing area, handling clean equipment showed direction for the staff to do the following: -Remove all mobile equipment from the area being mopped; -Sweep the floor, pushing all debris forward, using dustpan to remove debris; -Prepare detergent solution according to the manufacturer's instructions (a two compartment mop bucket with a mop press is prepared); -Mop one small area at a time, beginning at the rear of the room in a figure eight motion. Use a scraper…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an effective pest control system to control the flies for three residents (Resident #77, #96 and #250). The facility census was 101. Record review of the facility's policy titled, Pest Control, dated 3/2015, showed the following information: -To provide an environment free of pests; -The facility will have a pest control contract which provides frequency treatment of the environment for pests. It will allow for additional visits when a problem is detected; -Monitoring the environment will be done by the facility's staff; -Pest control problems will be reported promptly. 1. Record review of Resident #77's annual Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 6/26/19, showed the following information: -Cognitive skills intact; -Diagnoses of anxiety, depression, and manic depression (bipolar disease); -Extensive assistance required with bed mobility, transfers, dressing, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to document a complete assessment of a newly identified pressure ulcer, failed to timely obtain treatment orders for a newly identified pressure ulcer, and failed timely and consistently implement pressure-relieving interventions for one resident (Resident #96). The facility also failed to consistently implement pressure-relieving interventions, failed to perform wound care per acceptable infection control standards, and failed to follow physician's orders for wound care for one resident (Resident #77) who had a history of chronic pressure ulcers in a selected sample of 29 residents. The facility's census was 101. Record review of the facility's Wound Care and Treatment Nursing Guidelines, dated July 2015, included the following information: -It is the purpose of this facility to prevent and treat all wounds; -Care is taken to prevent contamination of the supplies and the surfaces used in wound care; -If the resident is soiled, cleaning of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to obtain physician orders in a timely manner for one resident's (Resident #65's) urinary (Foley) catheter care and treatment. A sample of 29 residents were selected for review in a facility with a census of 101. Record review of the facility's (undated) indwelling catheter care/change procedure, showed the following information: -The purpose of the procedure is to prevent infection and provide continuous drainage of the urinary bladder; -Equipment needed included a physician's order for catheter change; -For removal of the indwelling catheter, staff should check the physician's order for the changing of the catheter. 1. Record review of Resident #65's admission Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument, completed by facility staff, dated 6/06/19, showed the following information: -admitted to the facility on [DATE] from the hospital; -Cognitively intact; -Did not reject cares; -Required extensive…

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 ongoing communication with the dialysis (the cleaning of the blood with a machine due to the kidneys not working) center and failed to document the thrill/bruit (a vibrating sensation that can be felt) sensation for one resident (Resident #74) who received dialysis out of a sample of 29 residents selected for review in a facility with a census of 101. Record review of the facility's Nursing Guidelines Manual, dated March 2015, titled, Care of a Resident Receiving Dialysis, showed the following information: -To utilize the following guidelines to provide care for a resident that is receiving dialysis; -Care for the AV (arteriovenous) shunt/fistula/graft: -Keep the area clean and dry; -Feel for the thrill sensation daily; -Inspect the access for redness, swelling or warmth; -Watch for bleeding after dialysis; -Watch for signs of infection; -Checking the thrill sensation: Nurses will check the thrill daily and document daily. This…

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.