Stonebridge Maryland Heights

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent. A total of five errors occurred out of 33 opportunities for error due to residents not receiving their medications that were ordered and one medication not being the ordered strength, for one resident (Resident (R)50) of five residents observed for medication administration. The facility medication error rate was 15.15%. This failure had the potential to affect the accurate dosing of medication administered to the residents. Findings include: During medication administration observation on 01/29/25 at 8:37AM, Certified Medical Technician (CMT)3, administered/applied a four percent lidocaine patch to R50's right knee. Review of R50's Physician Orders dated May 31, 2024, in the electronic medical record (EMR) under the Orders tab indicated the physician's order was for a five percent lidocaine patch to R50's right knee. Further review of the Physician's Orders reveled physician orders for Fexofenadine HCl Tablet 60 MG BID (twice a day), Spironolactone…

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, interview, and facility policy review, the facility failed to ensure menus were followed and food preferences were honored for four residents (Resident (R)5, R65, R56, and R107) reviewed out of a total sample of 33 residents. The failure placed 140 of the 142 residents in the facility at risk of nutritional problems and dissatisfaction with their meals. Findings include: Review of the facility policy dated October 2017 titled Menus indicated the menus would be followed and provide a variety of foods and be approved by the Registered Dietitian (RD). Review of the facility policy dated October 2017 titled Food and Nutrition Services Staffing indicates the facility must take into consideration the preferences of each individual. Review of the week one menu provided to the survey team indicated that on 01/27/25 the lunch meal would be spaghetti with meat sauce, Italian tossed salad, brownie, and breadstick. An observation of the meal at 11:55 AM revealed the resident received peas and carrots…

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 review of the Dietary Manager's (DM) job description, the facility failed to provide palatable meals for four of four residents (Residents (R) 56, R9, R54, and R107) who complained their meals were not appetizing out of a total sample of 33 residents. This failure increased the risk of residents not being satisfied with their meals. Findings include: During an interview on 01/28/25 at 11:48 AM R56 stated that the food was horrible. R56 stated that she keeps food in her room so she can have something to eat when the meal tastes bad. The meal observation on 01/28/25 at 5:10 PM revealed patty melt, French fries, vegetable soup, chicken dumpling soup and a mixed fruit cup was served to residents. During an observation on 01/28/25 at 5:55 PM, R9 was observed licking the bread. R9 stated that she could not eat the sandwich because the bread was tough and soggy. R9 was observed to drink the soup and leave the table without finishing the meal. During an observation on 01/28/25 at 6:10 PM, R54 was observed throwing his sandwich off his plate. R54 was…

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

Based on interview, record review, and policy review, the facility failed to monitor the use of antibiotics for three of three residents (Resident (R)86, R81, and R102) reviewed for antibiotic stewardship of a total sample of 33 residents. Findings include: Review of the facility's policy titled, Infection Prevention and Control Program [IPCP], revised 11/2024, revealed . Antibiotic Stewardship: a. An antibiotic stewardship program will be implemented as part of the overall infection prevention and control program. b. Antibiotic use protocols and a system to monitor antibiotic use will be implemented as part of the antibiotic stewardship program . During an interview on 01/29/25 at 3:55 PM, the Infection Preventionist (IP) was asked to provide the facility's documentation of the antibiotic stewardship program from 01/01/24 through 12/31/24. The IP provided documentation dated 07/01/24 through 12/31/24. The IP confirmed that when she began as the IP, she was provided the facility's Infection Control Log and confirmed the log did not contain the required start and end date of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview, and policy review, the facility failed to ensure that a resident was assessed for self-administration of medications prior to medications being left at the bedside for one of one resident (Resident (R)68) reviewed for self-administration out of a total sample of 33 residents. This failure had the potential for the medication errors to be made. Findings include: Review of R68's Face Sheet located under the Resident Info tab in the electronic medical record (EMR) revealed R68 was readmitted to the facility on [DATE] with the diagnosis of chronic obstructive pulmonary disease, chronic diastolic congestive heart failure, and morbid obesity. Review of R68's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/01/25 and located under the MDS tab in the EMR revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated that R68 was cognitively intact. Review of R68's Physician Orders located under the Orders tab in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility failed to accurately code the Minimum Data Set (MDS) for one of 35 sampled residents (Resident (R)121). This failure reflected R121 was receiving care or treatments that was inaccurate. Findings include: Review of R121's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) revealed R121 was admitted to the facility on [DATE] with the diagnoses of anemia, orthostatic hypotension, and generalized weakness. Review of R121's quarterly Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 11/24/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This represented R121 was cognitively intact. R121 was also coded as receiving dialysis while a resident in the facility. Review of R121's Physician Orders located under the 'Orders tab in the EMR revealed no orders for dialysis. During an interview on 01/27/25 at 4:43PM, R121 stated, I have never been on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure the Pre-admission Screen and Resident Review (PASARR) Level I screen was completed prior to admission for one of four residents (Resident(R) 112) reviewed for PASARR out of a total sample of 33 residents. This created a potential failure to identify what specialized or rehabilitative services the resident needed and whether placement in the facility was appropriate prior to admission. Findings include: Review of R112's Profile tab of the electronic medical record (EMR) revealed he was admitted to the facility on [DATE] with diagnoses of unspecified dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, Parkinson's disease without dyskinesia, with fluctuations. Review of R112's annual Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 01/06/25 and located in the MDS tab of the EMR, revealed she scored five out of 15 on the Brief Interview for Mental Status (BIMS),…

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 to follow infection control guidelines during a wound care observation for one of three residents (Resident (R)1) reviewed for wounds out of 33 sampled residents. This failure had the potential for infections to be spread to vulnerable residents in a high-risk population. Findings include: Review of R1's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) revealed R1 was admitted to the facility on [DATE] with the diagnosis of diabetes mellitus, and congestive heart failure. Review of R1's quarterly Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 12/01/24 revealed one stage four and one unstageable pressure ulcer. Review of R1's Care Plan located under the Care Plan tab in the EMR and dated 09/04/24 with a focus of wound management. Interventions were If drainage present, obtain order for a culture. Measure ulcer on at regular intervals [sic]. Provide…

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 notify one resident's representative (Resident #1) of a newly acquired skin condition. The sample size was five. The census was 142. The Administrator was notified on 10/23/24, of the past non-compliance. The facility in-serviced nursing staff regarding notification and documentation of the notification to residents' responsible parties, regarding any new skin conditions or refusals of care concerning skin treatments. The deficiency was corrected on 9/26/24. Review of the facility's Acute Condition Changes policy, revised December, 2015, showed physicians and resident representatives shall be contacted in the case of an acute condition change. Review of the Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/7/24, showed: -Severe cognitive impairment; -Diagnoses included: Peripheral vascular disease (PVD, a disease that restricts blood flow to the lower extremities), lung…

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 one resident (Resident #1) with a pressure wound (skin or soft tissue injury that develops with prolonged periods of pressure over specific areas of the body) received the necessary treatments and services to promote healing by not thoroughly documenting skin assessments and wound progress and descriptions. The sample size was five. The census was 142. The Administrator was notified on 10/23/24, of the past non-compliance. The facility in-serviced nursing staff regarding completion and documentation of skin assessments, assessments and documentation of new wounds and the progress of the wounds, and the protocols to follow if wound healing is not progressing. The deficiency was corrected on 9/26/24. Review of the facility's Pressure Ulcer and Skin Breakdown policy, revised March, 2020, showed: -Assessment and Recognition: -The nurse shall describe and document/report the following: Full assessment of pressure sore including location,…

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 residents food that is palatable and at a safe and appetizing temperature for eight of 29 sampled residents (Residents #36, #123, #66, #122, #102, #47, #136 and #58) and for the residents who received hall trays. The census was 145. 1. Review of the facility's Resident Nutrition Services policy, revised July 2017, showed the following: -Policy: Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident; -Policy Interpretation and Implementation: The multidisciplinary staff including nursing staff, the attending physician and the dietitian will assess each resident's nutritional needs, food likes, dislikes and eating habits. They will develop a resident care plan based on this assessment. Residents shall receive prompt meal service and appropriate feeding assistance. Reasonable efforts will be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide residents with a homelike environment. The facility failed to keep soiled linen carts out of resident rooms. The facility also failed to ensure main entrances, dining room, hallways, and resident rooms were free of odors. The census was 145. Review of the facility's routine cleaning and disinfection policy, revised October 2022, showed: -Policy statement: It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible; -Routine cleaning and disinfection of frequently touched or visibly soiled surfaces will be performed in common areas, resident rooms, and at the time of discharge; -Cleaning considerations include, but not limited to, the following: -Dry cleaning procedures will be conducted before wet procedures; -Clean from areas that are visibly clean and least likely…

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 an ongoing activity program based on resident preferences, to support residents in their choice of activities and meet the needs of the residents. The facility failed to provide adequate organized activities in the evenings and on the weekends. The resident council representatives reported activities to be insufficient. In addition, residents observed and interviewed reported concerns with the activity program (Residents #36, #47, #102, #135, #108, #64 and #58). The census was 145. Review of the facility's Activity Evaluation policy, revised June 2018, showed: -Policy Statement: In order to promote the physical, mental and psychosocial well-being of residents, an activity evaluation is conducted and maintained for each resident at least quarterly and with any change of condition that could affect his/her participation in planned activities; -Policy Interpretation and Implementation included: -An activity evaluation is conducted as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure side rails were accurately assessed as a necessary device prior to installation and use. The facility also failed to obtain physician's orders for the use of side rails and failed to document usage in the residents' care plan for seven of 29 sampled residents (Residents #102, #27, #73, #45, #58, #84 and #59). The census was 145. Review of the facility's Proper Use of Side Rails policy, dated September 2022, showed: -Policy Statement: It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. If bed rails are used, the facility ensures correct installation, use, and maintenance of the rails; -Definitions; -Bed Rails are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes and sizes ranging from full to one-half, or one-eighth lengths.…

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

Based on observation and interview, the facility failed to ensure that medications kept in facility medication rooms and on medication carts were within the date of expiration and failed to ensure wound dressings were disposed of when expired. The facility census was 145. Review of the facility's Storage of Medications policy, revised in April 2007 and in use at the time of survey, showed: -The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed; -Facility nursing staff are responsible for maintaining medications stored in facility medication rooms and on facility medication carts. 2. Observation of the 200 hall medication room on 9/12/23 at 10:25 A.M., showed: -A single-dose injection pen of Trulicity (a medication used for the treatment of type 2 diabetes, a chronic condition that affects the way the body processes blood sugar (glucose)) 0.75 milligram (mg) with no name or label stored in the medication room refrigerator; -Four boxes of Levothyroxine (a medicine used to treat…

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

Based on observation, interview and record review, the facility failed to have corresponding recipes for meals served, to ensure residents were served meals in accordance with physician orders and provide an alternate menu (Residents #36, #92 and #58). The sample was 29. The census was 145. 1. Review of the lunch menu for 9/14/23, showed the following: -Resident choice meal with 3 ounces of protein; -Residents voted to have fried rice and shrimp for a meal. Observation of the lunch meal prep on 9/14/23, showed the following: -At 10:11 A.M., the Dietary Manager scooped various amounts of rice, scrambled eggs and meat with no precise measurements. After the food was fried, she placed the fried rice mixture into a pot for the steam table. -No recipe was followed. During an interview on 9/14/23 at 9:06 A.M., the Dietary Manager said she was not following a recipe due to the fried rice being easy to make. Each resident would receive the correct amount of protein due to how much meat was in the fried rice. 2. Review of Resident #36's electronic physician order sheet (ePOS), showed an…

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 food was prepared under sanitary conditions by failing to wear beard nets and failing to ensure proper hand washing/glove techniques were followed. The Sample was 29. The Census was 145. 1. Review of the facility's Preventing Foodborne Illness: Employee Hygiene and Sanitary Practices policy, dated October 2008, showed the following: -Policy: Food Services employees shall follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness; -Procedure: All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents; -Employees must wash their hands: After personal body functions (i.e., toileting, blowing/wiping nose, coughing, sneezing, etc.); after using tobacco, eating or drinking; whenever entering or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents had complete, accurate, and individualized care plans to address the specific needs of four residents (Residents #68, #102, #36 and #27). The sample was 29. The census was 145. Review of the facility's Comprehensive Care Plan policy, revised October 2022, showed: -Policy Statement: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment; -Policy Explanation and Compliance Guidelines included: -The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined 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 adequately provide assistance to promote good nutrition and maintain acceptable parameters of nutritional status to provide one resident (Resident #28), with significant weight loss, nutritional needs as ordered. The sample size was 29. The census was 145. Review of the facility's Resident Nutrition Services policy, dated July 2017, showed: -Policy Statement: Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident; -Policy Interpretation and Implementation: The multidisciplinary staff, including nursing staff, the Attending Physician and Dietitian will assess each resident's nutritional needs, food likes, dislikes and eating habits: -They will develop a resident care plan based on this assessment; -Provide prompt meal service and appropriate feeding assistance; -Nursing personnel or feeding assistants will provide assistance with eating and ensure that assistive…

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 medical records were accurately documented in accordance with acceptable professional standards of practice when staff documented nutritional health shakes as administered for one resident (Resident #28), eye drops as administered for one resident (Resident #47) and Juven (nutritional powder used for wound healing) as administered for one resident (Resident #12), when the health shakes, eye drops, and Juven were not provided. The census was 145. Review of the facility's Charting and Documentation policy, revised July 2017, showed: -Policy statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care; -Policy interpretation 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 provide dignity to residents by failing to provide meals to all residents at a table at the same time, and treat residents in a respectful manner during meal service. Furthermore, the facility failed to respect residents' privacy when a staff member walked into residents' rooms while talking on a cell phone. The sample was 35 and the census was 185. 1. Observation on 12/18/19 in the main dining room during the dinner meal, showed the following: -At 4:45 P.M., three residents sat at a table, two of the residents had their food and were almost done eating. One of the residents sat at the same table with no food in front of him/her. At 5:04 P.M., the third resident received his/her tray; -At 4:50 P.M. two residents sat at a table. One of the residents ate and the other one did not have a tray. At 5:15 P.M., the other resident received his/her tray. Observation on 12/19/19 in the main dining room during the breakfast meal, showed the following: -At 7:40 A.M. at table #23, one resident had a food tray in front 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 ensure the residents' environment was maintained in a clean, orderly and comfortable manner regarding floors, walls, resident equipment including tube feeding stands, cubicle curtains, call lights and water dispensers. This affected nine sampled resident rooms, the dining rooms, water dispensers for residents and the shower/bathrooms. The sample was 35 and the census was 185. 1. Observation of Resident #121's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/5/19, showed the resident was totally dependent on staff for activities of daily living (ADLs). Review of the resident's current physician's orders, showed the resident received tube feedings every four hours. Observation of the resident's tube feeding pump from 12/18-12/23/19, during the survey, showed the pump had copious amounts of brownish dried splatters and spills along the base of the pump. 2. Observation 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's orders for dialysis (process for removal of waste and excess water from the blood due to kidney failure) treatment and care, obtain daily weights, administer medication on dialysis days as ordered, clarify physician's order for an indwelling urinary catheter, apply elastic support stockings, follow physician's orders for correct administration of oxygen and obtain physician's order for oxygen therapy, for five sampled residents (Residents #322, #112, #49, #34 and #61). The sample was 35. The census was 185. 1. Review of Resident #322's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/8/19, showed the following: -No cognitive impairment; -Received dialysis; -Diagnoses included atrial fibrillation (A-fib, irregular heartbeat), blood clots, heart failure, high blood pressure, end stage renal disease (ESRD-kidney failure) and high cholesterol. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that two residents received treatment and care in accordance with professional standards of practice by not effectively communicating a hospice resident's (Resident #83) significant weight loss to his/her guardian and document interventions in place prior to a resident (Resident #96) being sent out to the hospital with a change in condition. The sample was 35. The census was 185. 1. Review of Resident #83's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/22/19, showed the following: -admitted to the facility on [DATE] on hospice care; -Moderately impaired cognitive skills for daily decision making; -Total dependence on staff for personal hygiene, eating and toileting; -Upper and lower extremity impairment; -Two-Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide restorative therapy services for residents who had physician orders to provide these services. This affected five of eight sampled residents who had order for restorative services (Resident's #49, #121, #166, #96 and #34). The sample was 35. The census was 185. 1. Review of Resident #49's physician progress notes, showed the following: -Current diagnoses including dementia, coronary obstructive pulmonary disease (COPD, a lung disease), high blood pressure, psychosis, difficulty in walking, generalized muscle weakness, other abnormalities of gait and mobility, schizoaffective disorder, bipolar disorder and cataracts; -On 7/24/19 at 7:44 A.M., resident fell coming out of room. Complained of falling in small space between the bed and dresser. He/she hit his/her knee on the floor and sustained a skin tear; -On 9/29/19 at 7:32 P.M., the nurse was informed that the resident fell. Nurse came into assess resident and and noticed he/she lay…

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 protect one resident (Resident #34) from injury during a transfer, failed to follow their policy and the manufacturer's recommendations during two of two resident (Resident's #155 and #101) transfers with a Hoyer lift (mechanical lift used to transfer a resident from one surface to another), failed to follow their policy after a resident's fall (Resident #49) and failed to prevent access to razors and chemicals in three of four central bathrooms, leaving them available to all residents who were able to move freely around the facility. The sample size was 35. The census was 185. 1. Review of Resident #34's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/2/19, showed the following: -No cognitive impairment; -Unable to ambulate; -Limited assistance required for transfers, bed mobility, dressing, toileting and personal hygiene; -Impairment to upper extremity on one side and no…

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 certified nurse aides (CNAs) received the required 12 hours of training and have a system to track the hours for four of four sampled CNAs reviewed who worked at the facility for over a year. The census was 185. 1. Review of CNA K's training record, showed the following: -Date of hire (DOH), 4/3/18; -Total hours of training completed for the last full year of employment, 8 hours. 2. Review of CNA S's training record, showed the following: -DOH, 7/19/11; -Total hours of training completed for the last full year of employment, 8.75 hours. 3. Review of CNA V's training record, showed the following: -DOH, 10/12/14; -Total hours of training completed for the last full year of employment, 6.25 hours. 4. Review of CNA W's training record, showed the following: -DOH, 3/2/18; -Total hours of training completed for the last full year of employment, 4.75 hours. 5. During an interview on 12/19/19 at approximately 10:00 A.M., assistant Director of Nursing (ADON) N said they did not currently have a process in place to track CNA…

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 establish a system of records of receipt and disposition of all controlled drugs in sufficient detail, to ensure an accurate reconciliation of controlled substances. The facility failed to properly document narcotic counts for the controlled substances for seven of nine medication carts. The census was 185. 1. Review of the Certified Medication Technician (CMT) narcotic count sheet, dated 12/1/19 through 12/18/19, on the 200 East Hall, showed the following: -No signature by the off-going CMT, a total of 26 shifts; -No signature by the on-coming CMT, a total of 28 shifts; -Total narcotic drug cards not documented as counted, a total of 15 shifts. 2. Review of the nurses narcotic count sheet, dated 12/1/19 through 12/18/19, on the 100 [NAME] Hall, showed the following: -No signature by the off-going nurse, a total of 16 shifts; -No signature by the on-coming nurse, a total of 17 shifts; -Total narcotic drug cards not documented as counted, a total of 4…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure food items were labeled, dated and sealed appropriately; failed to maintain clean vents in the Manor dining rooms; failed to ensure the kitchen floors were maintained free of debris and dirt build up and failed to ensure dietary staff used safe food handling techniques during meal service. In addition, staff dried clean dishware on a rusty drying rack. The census was 185. 1. Observations of the main kitchen on 12/15/19 at 6:33 A.M., showed the following: -Signs on the exterior of the reach in refrigerators, showed Label and date everything before it goes in refrigerator; -In the reach in refrigerator near the coffee station, a tray with at least 40, two ounce (oz) clear plastic containers of salad dressing with no dates; -In the reach in freezer near the ice machine, an unopened, undated box of five pound bags of thawed liquid eggs. Directions on the box, showed to keep frozen; -A wired drying rack near the three vat sink with rusted surfaces 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, facility staff failed to follow acceptable infection control practices to prevent the spread of infection during perineal (area between the thighs, extending from the pubic bone to the tail bone) care by not handwashing and touching a resident with soiled gloves (Residents #105, #110 and #54), allowing a catheter bag to rest on the floor with urine unable to drain from looped tubing (Resident #88), not cleansing the glucometer (device used to check blood sugar) with an approved disinfectant before and after use (Resident #272), placing the glucometer on an unclean surface and transporting it under his/her axilla (arm pit) (Resident #34) and allowing a nasal cannula (a device for delivering oxygen by way of two small tubes that are inserted into the nares) to rest on a bed and seat of a recliner (Resident #61). The sample was 35. The census was 185. 1. Review of Resident 105's electronic medical record, showed the following: -admission date of 7/18/19; -Diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide a final account of resident trust fund balances within 30 days to the individual or probate jurisdiction administering the resident's estate for one expired resident (Resident #22) and for two discharged residents (Residents #25 and #38). The facility census was 185. 1. Record review of the facility maintained Discharge Report dated [DATE], showed Resident #22 expired on [DATE]. Record review of the facility maintained Resident Fund Petty Cash Box, for the period [DATE] through [DATE], showed an envelope with Resident #22's name written on it. Facility staff failed to refund Resident #22's funds held in the Resident Fund Petty Cash Box in the amount of $13.00 as of [DATE] (100 days after Resident #22 expired.) During an interview on [DATE] at 9:45 A.M., the Business Office Assistant said he/she did not know why the money had not been refunded back to Resident #22. During an interview on [DATE] at 10:21 A.M., the Accounts Receivable Specialist…

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 notify the Department of Health and Senior Services (DHSS) immediately after a resident alleged his/her leg was fractured during an improper transfer (Resident #34) and after the discovery of an injury of unknown origin to a non-verbal resident (Resident #83). The sample size was 35. The census was 185. 1. Review of Resident #34's quarterly Minimum Data Set (MDS), dated [DATE], showed the following: -No cognitive impairment; -Unable to ambulate; -Limited assistance required for transfers, bed mobility, dressing, toileting and personal hygiene; -Impairment to upper extremity on one side and no impairment to lower extremities; -Occasional pain at a level of four on a zero to 10 scale; -Received non scheduled pain medication; -No falls; -Diagnoses included heart failure, kidney failure, chronic lung disease and anxiety. Review of the care plan, dated 6/7/19 and last revised on 12/18/19, showed the following: -Problem: Resident is at risk for falls due 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 follow their policy to conduct a complete and thorough investigation of a fracture to one resident's leg (Resident #34) and an injury of unknown cause to a nonverbal resident (Resident #83) and failed to submit their investigation in the required time frame to the Department of Health and Senior Services (DHSS). The sample size was 35. The census was 185. 1. Review of Resident #34's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/2/19, showed the following: -No cognitive impairment; -Unable to ambulate; -Limited assistance required for transfers, bed mobility, dressing, toileting and personal hygiene; -Impairment to upper extremity on one side and no impairment to lower extremities; -Occasional pain at a level of four on a zero to 10 scale; -Received non scheduled pain medication; -No falls; -Diagnoses included heart failure, kidney failure, chronic lung disease and anxiety. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to notify the physician and family, did not attempt new interventions and did not monitor consumption for one resident with a significant weight loss of 10.52% over three months (Resident #155). Furthermore, the facility failed to adequately monitor and implement additional meal supplements for one resident with significant weight loss of 9.63% in three months and a significant weight loss of 15.23% in six months (Resident #96). The sample was 35 and the census was 185. 1. Review of Resident #155's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/27/19, showed the following: -Severe cognitive impairment; -Dependent on staff for transfers and personal hygiene; -Extensive assistance required for bed mobility, dressing and toileting; -Weight loss of 5% in last month or 10% or more in the last six months and not on a physician prescribed weight loss program; -Diagnoses included…

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.