Parkdale Manor Health & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the policy review, record review, and interview, the facility failed to follow the recommendations to obtain weekly weights for one of two residents (Resident (R) 27) reviewed for nutrition out of a total sample of 18 resident which caused inadequate tracking of weight loss or gain. The facility census is 28. Review of the facility's policy titled Weighing and Measuring revised March 2011 revealed .The purpose of this procedure are to determine the resident's weight and height, to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident, and provide a baseline height in order to determine the ideal weight of the resident . Review of the Face Sheet located in the Profile tab in the electronic medical record (EMR) revealed R27 was admitted to the facility on [DATE] with diagnoses which included acute and chronic respiratory failure and moderate protein-calorie malnutrition. Review of the quarterly Minimum Data…

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, record review, and policy review, the facility failed to ensure the oxygen (O2) concentrators had dust free filters on the inlet where the air came into the machine for one of two residents (Resident (R) 25) reviewed for oxygen usage out of a total sample of 18 residents. This deficient practice had the potential for increased chance of infection and unnecessary respiratory treatment. The facility census is 28. Review of the facility's policy titled, Departmental (Respiratory Therapy)- Prevention of Infection revised November 2011, revealed, Purpose: The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. Steps in the Procedure Infection control considerations Related to oxygen Administration. 9.Wash filters from oxygen concentrators every seven days with soap and water. Rinse and squeeze dry. 1. Review of R25's undated Face Sheet located in R25's electronic medical record (EMR) under the Profile tab, indicated diagnoses to include…

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, interviews and record reviews, the facility failed to assure staff followed acceptable standards of practice for one (1) of the five (5) sampled residents, (Resident #1), when staff failed to follow provider orders, remove a resident's surgical staples in a timely manner, and charted that the surgical staples had been removed per provider orders and were not actually removed. The facility census was 24. The facility did not provide policies and procedures relating to physician orders and weekly skin assessments. Review of the facility's policy for Wound Care, revised October, 2010, showed: - The purpose of this procedure is to provide guidelines for the care of wounds to promote healing; - Verify that there is a physician's order for this procedure; - Review the resident's care plan to assess for any special needs of the resident; - The following information should be recorded in the resident's medical record: - (1.) The type of wound care given. - (2.) The date and time the wound care 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to promote an environment respectful of the rights of each resident to make choices about significant aspects of their lives when staff did not offer evening (HS) snacks to all residents. This affected eight of 12 sampled residents, (#1,#2, #4, #9, #12 and #16) and other residents who attended the resident group interview. The facility census was 22. Review of the facility's policy for serving snacks between meal and bedtime, revised September 2010, showed, in part: - The purpose of this procedure is to provide the resident with adequate nutrition; - Review the resident's care plan and provide for any special needs of the resident; - The person performing this procedure should record the following information in the resident's medical record: the date and time the snack was served; the amount of snack eaten by the resident; if the resident refused the snack, the reasons why and the intervention taken. 1. Review of Resident #9's quarterly…

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.

During an interview and record review, the facility failed to maintain a Department of Health and Senior Services (DHSS) approved surety bond that was equal or greater than one and one-half times the average monthly balance for the residents' personal funds for the last 12 consecutive months from July 2022 through June 2023. This has the potential to affect all residents who had money in the trust account. The facility census was 22. Review of the facility policy, Surety Bond, dated March 2021, showed: -Our facility has a current surety bond to assure the security of all residents' personal funds deposited with the facility; -A surety bond is an agreement between the facility, the insurance company, and the resident or the State acting on behalf of the resident, wherein the facility and the insurance company agree to compensate the resident for any loss of resident's funds that the facility holds, accounts for, safeguards, and manages; -This facility holds a surety bond to guarantee the protection of residents' funds managed by the facility on behalf of its residents; -All funds…

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 they utilized the correct Skilled Nursing Facility Advance Beneficiary Notice of non- coverage (SNFABN) form (a form that provides information to residents/beneficiaries so that they can decide if they wish to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility), for two of three residents sampled for beneficiary notifications (Residents #5 and #12). The facility census was 22. Review of the facility policy, Medicare Advance Beneficiary Notice, dated April 2021, did not address the utilization of the correct 2020 dated ABN form. Review of Resident #5's Beneficiary Notice CMS-10055 form showed his/her last covered day of Part A services was 2/28/23. The resident signed the form on 2/16/23. The facility did not use the most updated form from 2020. The facility issued the old form dated 2018. Review of Resident #12's Beneficiary Notice CMS-10055 form showed his/her last covered day of Part A services was 2/28/23. The residents' representative signed the form…

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 interviews, the facility failed to maintain a clean and comfortable homelike environment when staff failed to: properly clean resident room floors, properly strip and re-wax to maintain tiles around the base of resident toilets. Additionally, the facility failed to repair damaged base boards in resident room [ROOM NUMBER], fix a dragging door to restroom in room [ROOM NUMBER], and repair a damaged circular metal floor plate in the 500 hall; As well as failure to maintain the entrance to the facility by not removing spider webs, and a bird's nest from above main entry doors. This effected the quality of life for all residents in the facility. The facility census was 22. Review of the facility policy on floor cleaning and maintenance dated December of 2009, showed: - Floors shall be maintained in a clean, safe, and sanitary manner; - All floors shall be mopped/cleaned/vacuumed daily in accordance with our established procedures; - Floor cleaning procedures are maintained by 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 develop and implement a comprehensive plan of care which included measurable objectives and timeframe's for two sampled resident, (Resident #24 and Resident #9). Staff failed to implement a comprehensive person-centered plan of care that addressed hearing issues for Resident #9 and develop a plan of care to address Resident #24's diagnosis of a Post Traumatic Stress Disorder (PTSD, a disorder that develops in some people who have experienced a shocking, scary or dangerous event). The facility census was 22. Review of the facility's Comprehensive, Person-Centered Care Plan Policy, revised December 2016, showed: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; -The comprehensive, person-centered care plan will include: o Measurable time tables o Describe services that are to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to complete a discharge summary for two residents out of the two sampled closed resident records (Resident #15 and Resident #28). The facility census was 22. The facility did not provide a policy addressing discharge summaries. 1. Review of Resident #15's admission Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 4/28/23 showed: - No cognitive impairment; - Assistance of one staff for Activities of Daily Living (ADL's); - Diagnosis included, high blood pressure and depression; - Resident planned to return to the community. Review of the resident's care plan, dated 4/21/23 showed: -The resident is a full code; -The resident would like to return home following his/her rehabilitation stay. Review of the nurses' notes dated 5/5/23 at 9:16 A.M. showed the resident left the facilty with a friend. Review the of resident's medical record did not show a discharge summary. During an interview on 8/3/23 at 5:40 P.M., the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to ensure that seven of 12 sampled residents (Residents #1, #20, #12, #2, #16 #19, #23), who required staff assistance, were provided with adequate assistance for activities of daily living (ADL's: tasks completed to care for oneself daily such as bathing, dressing, moving from a chair to bed, and personal hygiene), as well as failed to provide proper incontinence care for Residents #16, #23, The facility census was 22. Review of the facility ADL policy dated March 2018, showed: -Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, personal and oral hygiene; -Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care),…

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 staff used proper techniques to reduce the possibility accidents or injuries when transferring two sampled residents (Resident #11 and Resident #12) during the use of a mechanical lift transfer. The facility census was 22. Review of the manufactures instructions for the Drive mechanical lift, dated July 2020 showed: -Keep the legs of the lift in the closed position while transferring the resident; -Do not lock the rear casters of the patient lift when lifting an individual; -Locking the rear castors could cause the patient lift to tip. 1. Review of Resident #23's quarterly MDS (a federally mandated assessment tool completed by facility staff), dated 5/17/23, showed: -Severe cognitive impairment; -Extensive assistance of two staff with bed mobility, transfers, toileting and personal hygiene; -Incontinent of bowel and bladder; -Receiving Hospice services; -Diagnoses included, dementia, high blood pressure, kidney disease and diabetes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure staff provided proper respiratory care for two of 12 sampled residents (Residents #14 and #19) when staff failed to: effectively clean oxygen concentrator filters, properly install oxygen concentrator humidifier bottles, properly label and date oxygen concentrator tubing bags, and additionally failed to follow a physician order by providing the accurate amount of ordered oxygen liters. The facility census was 22. Review of the facility's oxygen administration policy, dated October 2010, showed: - The purpose of the policy is to provide guidelines for safe oxygen administration; - Staff is to review the physician's order for oxygen administration; - A humidifier bottle is necessary when performing this procedure; - Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered; - Check the humidifying jar to be sure they are in good working order and are securely…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to provide adequate staffing to meet the needs of residents due to extended call light response times, which affected seven of 12 sampled residents, (Resident #1, #2, #5, #9, #11, #16 and #19), failed to provide showers for Resident #1, #2, #16 and #19, and failed to provide a bedtime snack for Resident #1, #2, #4, #9, #12 #16 and #19, and other residents who attended the resident group interview. The facility census was 22. Review of the facility's policy for answering call lights, revised March 2021, showed, in part: - The purpose of this procedure is to ensure timely responses to the resident's requests and needs; - If the resident needs assistance , indicate the approximate time it will take for you to respond; - If the resident's request requires another staff member, notify the individual; - If the resident's request is something you can fulfill, complete the task within five minutes if possible; - If you are uncertain as to whether…

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 a Registered Nurse (RN) for eight consecutive hours per day seven days a week. This had the potential to affect all residents. Facility census was 22. The facility did not provide a policy for RN coverage. Review of the facility's Payroll Based Journal data (PBJ- a report that provides staffing data set information submitted by nursing homes on a quarterly basis) for Quarter 2 2023 (January 1 to March 31) showed no RN hours on 1/1, 1/14, 1/15, 2/6, 2/11, and 2/12. Review of staffing sheets confirmed there was no RN hours on 1/1, 1/14, 1/15, 2/6, 2/11, and 2/12. Review of staffing schedules for May 2023 showed no RN on the following days: 5/3, 5/4, 5/8, 5/10, 5/11, 5/12, 5/13, 5/14, 5/16, 5/18, 5/19, 5/22, 5/26, and 5/30. Review of daily staffing sheets for May 2023 showed no RN hours on 5/13, 5/14, 5/19, 5/21, 5/27, and 5/28. Review of staffing schedules for June 2023 showed no RN on the following days: 6/1, 6/2, 6/6, 6/7, 6/8, and 6/12 through 6/30. Review of daily staffing sheets for June 2023 showed no RN hours…

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

Based on observations, interviews and record review, the facility failed to ensure staff administered medications with a medication error rate of less than 5%. Facility staff made nine medication errors out of 25 opportunities for error which resulted in a medication error rate of 36%, which affected five sampled residents, (Resident #2, #6, # 9, #18, and #19). The Facility census was 22. Review of the facility's policy for administering medications, revised April 2019, showed: - Medications are administered in a safe and timely manner, and as prescribed; - The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Review of the facility's policy for nasal administration, revised 8/20, showed in part: - Medications will be administered in a safe and effective manner. The guidelines in this policy detail how to administer nasal sprays or drops; - When required by manufacturer, prime the pump by holding the bottle upright 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 observations, interviews, and record review, the facility failed to have a Quality Assurance and Performance Improvement (QAPI) plan and failed to have a plan that contained all required elements. Facility census was 22. Review of the facility Quality Assurance and Performance Improvement (QAPI) Program Policy dated February 2020, showed: - The facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for residents; - The QAPI program will provide a means to measure current and potential indicators for outcomes of care and quality of life; - The QAPI program will provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators; - The QAPI program will reinforce and build upon effective systems and processes related to the delivery of quality care and services; - The QAPI program will establish systems through which to monitor and evaluate corrective actions; - The owner and/or governing board…

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 develop a comprehensive, data-driven quality assessment and assurance (QAA) activities and a quality assurance performance improvement (QAPI) program that focused on outcomes of care and quality of life when they failed to provide documentation and evidence of its ongoing QAA/QAPI program. The facility census was 22. Review of the facility Quality Assurance and Performance Improvement (QAPI) Program Policy dated February 2020, showed: - The facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for residents; - The QAPI program will provide a means to measure current and potential indicators for outcomes of care and quality of life; - The QAPI program will provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators; - The QAPI program will reinforce and build upon effective systems and processes related to the delivery of quality care…

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 maintain a quality assessment and assurance (QAA) committee that meets at least quarterly and as needed and contains the minimum required members. The facility census was 22. Review of the facility Quality Assurance and Performance Improvement (QAPI) Program Policy dated February 2020, showed: - The facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for residents; - The QAPI program will provide a means to measure current and potential indicators for outcomes of care and quality of life; - The QAPI program will provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators; - The QAPI program will reinforce and build upon effective systems and processes related to the delivery of quality care and services; - The QAPI program will establish systems through which to monitor and evaluate corrective actions; - The owner and/or governing…

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 follow and review their infection control polices at least annually, and additionally failed to provide care in a manner to prevent infections or the possibility of acquiring infections when they did not change their gloves or wash hands between dirty and clean tasks which affected Resident #23. The facility additionally failed to ensure that new staff received tuberculin skin testing and that it was completed prior to new employees working, which could have an an negative impact on all residents. The facility census was 22. Review of the facility's Infection Prevention and Control Policy, with a revision date of October 2018, showed: -An infection and control program is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections; -The elements of the infection and control program consist of procedures, surveillance,…

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

Based on observations, interviews and record review the facility failed to provide appropriate treatment and services to maintain the ability to communicate for one of 12 sampled residents, (Resident #9). The facility census was 22. The facility did not provide a policy related to scheduling appointments for residents. 1. Review of Resident #9's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/5/23 showed: - Cognitive skills intact; - Minimal difficulty with hearing; - Required extensive assistance of two staff for bed mobility; - Dependent on the assistance of two staff for transfers; - Upper and lower extremity impaired on both sides; - Diagnoses included congestive heart failure (CHF, accumulation of fluid in the lungs and other areas of the body), chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing), dementia and anxiety. Review of the resident's care plan, revised 7/20/23 showed it did not address the resident's hearing issues. Observation and interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed assess one resident (Resident #24) for a history of trauma and provide trauma informed care for a diagnosis of Post Traumatic Stress Disorder (PTSD, a mental health condition that is triggered by a terrifying event). The facility census was 22. Review of the facility's Trauma Informed Care policy, revised March 2019, showed: -The purpose of this policy is to guide staff in appropriate and compassionate care specify to individuals that have experienced trauma; -All staff are provided in-service training about trauma and its impact on health and Post Traumatic Stress Disorder (PTSD, a mental health condition that is triggered by a terrifying event); -Nursing staff are trained on trauma assessment and how to identify triggers associated with re-traumatizing the resident; -Caregivers are taught strategies to help eliminate or mitigate a resident's triggers; -The comphrensive assessment should be used as a screening tool to identify a history of…

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

Based on observations, interviews, and record reviews, the facility failed to provide residents with Saturday mail delivery. This affected all of the residents residing in the facility. The facility census was 30. 1. Review of the undated Resident Rights policy showed: - The right to have communication with and access to people and services inside and outside of the facility. - The right to exercise his/her rights as a resident of the facility and as a resident of the United States. - The right to have access to a telephone, email, and mail. - The right to communication in person, by mail, email, and telephone with privacy. 2. No mail delivery policy was provided. 3. During the resident council meeting on 8/25/21 at 2:30 P.M. the resident's said: - They do not regularly get their mail delivered on Saturday's. - Five out of 11 residents said they would like to get their mail delivered on Saturday's. 4. During an interview on 8/27/21 at 10:28 A.M. Licensed Practical Nurse (LPN) A said: - Yes, the resident's get their mail delivered on Saturdays. - He/she does not know who is…

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

Based on interview and record review, the facility failed to provide the services of a Registered Nurse (RN), other than the Director of Nursing (DON), for eight consecutive hours per day, seven days a week. This affected all the residents in the facility. The facility census was 30. The facility did not provide a policy. 1. Review of the staffing schedule dated, July, 2021, showed two days where the facility did not have an RN working. Review of the staffing schedule dated, August, 2021, showed six days where the facility did not have an RN working. During an interview on 8/24./21, at 11:12 A.M., the Administrator said: - The Interim DON is the Corporate Nurse; - The new DON will start on 9/1/21. During an interview on 8/27/21, at 4:39 P.M., the Interim DON said: - The facility does not have an RN to work eight hours a day, seven days a week.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to ensure store food in a sanitary manner and failed to maintain the kitchen and dry storage area in a sanitary manner. This affects all residents who receive their food from the facility's kitchen. The facility census was 30. Observation on 8/24/2021 at 12:31 P.M. of the kitchen showed: -the floor under the dishwashing sink was dirty with debris and dark matter -a substance was splattered several places on the ceiling, near the center of the ceiling and above the door by the dishwasher -a black matter on the floor along the edging below the cabinets -the fire extinguisher is resting on the floor -the underside of the hood above the stove is dirty with grease and dust -the drain for the griddle is dirty with grease and food particles -vent over the hanging pots and pans is dusty -the large trash can near the stove does not have a lid -a frozen coffee drink belonging to staff in the large stand up freezer -an open package of sausage patties,…

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 they conducted a complete criminal background check (CBC) through the Missouri State Highway Patrol (MSHP) for one of five staff members hired since the last full survey and who were selected for review. The facility census was 30. Review of the facility's Abuse Prevention Program policy, dated August 2006, showed: -The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. -The facility conducts employee background checks and will not knowingly employ any individual who has been convicted of abusing, neglecting, or mistreating individuals. -Comprehensive policies and procedures have been developed to aid the facility in preventing abuse, neglect, or mistreatment of the residents. The abuse prevention program provides policies and procedures…

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, within 14 days after a facility completes a resident's assessment, electronically transmit encoded, accurate, and complete Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) data to the Centers for Medicare and Medicaid Services (CMS) System for quarterly reviews as well as upon a resident's transfer, reentry, discharge and death, which affected one of 12 sampled residents (Resident #1) and three additionally sampled residents (Residents #235, #236 and #237). The facility census was 30. Review of the facility's MDS Completion and Submission Timeframes, revised July 2017, showed the facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. The assessment coordinator or designee is responsible for ensuring that resident assessments are submitted to CMS' system in accordance with current and federal guidelines. 1. Review of Resident #1's electronic medical record (EMR) showed staff opened a MDS in American Health Tech…

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 staff developed, implemented and updated, person-centered care plans that included measurable objectives to meet the residents needs, condition and risks for 4 out of 12 sampled residents, (Resident #4, #5, #7, #23.)The facility census was 30. Review of the care plan policy dated 2001 and revised December 2016 showed: - The Interdisciplinary Team (IDT) with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. - The care plan interventions are developed as a result of the comprehensive assessment. - The comprehensive, person-centered care plan will include: a. Measurable objectives and goals. b. Describe the services that are to be provided to attain or maintain the resident's highest practicable physical, mental, and psychosocial well being. c. Include the resident's stated goals upon admission and desired outcomes. d. Incorporate…

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, interviews, and record review, the facility failed to ensure that the residents remained free from accident hazards because water from the tap is to hot, which affected 2 (Resident #7 and #19) out of 12 sampled residents, and staff did not use proper technique during transferring with a gait belt (a belt placed around the waist to aid in transferring the residents from one area to another), which affected two of 12 residents, (Resident #19 and #23). The facility census was 30. Review of the policy regarding checking water temperatures included: - The policy was not dated. - The dial thermometer is accurate to 1 to 2 degrees Fahrenheit, however should be calibrated on a regular basis. - The water being tested should run 3 to 5 minutes. - Insert the stem of the thermometer into the stream of running water, fully immersing the sensor. - The temperature should be ready to read after 10 to 15 seconds in the running water. Review of the water temperature log dated 7/28/21 showed: - Temperature 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, interviews and record review, the facility failed to assure that staff provided proper respiratory care when the staff failed to date oxygen tubing, failed to properly clean oxygen concentrator filters, and failed to cover nebulizer masks and bilevel positive airway pressure (BiPAP) masks. Which affected four of 12 sampled residents, (Resident #7, #19, #17 and #21) . The facility census was 30. 1. The facility did not provide a policy . 2. Review of Resident #7's admission Minimum Data Set (MDS, a federally mandated assessment instrument completed by the staff), dated 5/16/21 showed: - Brief Interview for Mental Status (BIMS, an assessment tool used to determine the resident's cognitive status), score of 15, indicating that the resident is cognitively intact. - Activities of daily living (ADLs', activities that a resident is able to complete with no or minimal assistance), dependence on staff for transfers, dressing, toileting, and personal hygiene - Frequently incontinent of bowel 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 observations, interviews, and record review, the facility failed to ensure staff properly stored and discarded resident medications, stock medications, and treatment supplies. Staff failed to date medications when opened and failed to ensure medications are kept in a secure manner. Staff failed to ensure insulin Flexpens were dated when opened, which affected three of 12 sampled residents, (Resident #5, #10 and #28). The facility census was 30. 1. Review of the facility's policy for administering medications , revised April 2019, showed, in part: - Medications are administered in a safe and timely manner, and as prescribed; - The expiration/beyond use date on the medication label is checked prior to administering.; - When opening a multi-dose container, the date opened is recorded on the container. Review of the facility's insulin administration policy, revised September 2014, showed, in part: - The purpose is to provide guidelines for the safe administration of insulin to residents with diabetes; - The policy did not address insulin pens dated when opened. 2. 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.

Based on observation, record review and interviews, the facility failed to ensure each resident received foods prepared in a way to conserve nutritive value, flavor and appearance and failed to serve foods that are a safe and appetizing temperature. The facility census was 30. The facility did not provide dietary policies. An observation of the lunch meal service on 8/26/2021 at 12:11 P.M. showed: -The lunch meal consisted of a marinated chicken breast, cooked broccoli, garlic breadstick, cottage cheese. -The broccoli was very mushy and had little flavor. An observation of the evening meal tray on 8/26/2021 at 5:28 PM showed: -The meal consisted of cheesy ham hashbrown casserole, garlic breadstick, lettuce salad with ranch dressing, and chocolate pudding with vanilla wafer cookies. -The casserole was 170.7 degrees, the breadstick 120.6 degrees, the lettuce salad 53.2 degrees, the pudding 54.6 degrees. -The casserole consisted of hashbrown potatoes, ground ham, a cream sauce and melted cheese on top. It tasted of very salty ham. The breadstick was soft and tasted good. The lettuce in…

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

Based on observation and interviews the facility failed to provide a safe, functional and comfortable environment for residents, staff and the public when they did not keep the parking lot in good repair and failed to maintain all areas of the facility. The facility census was 30. Observation on 8/24/21 starting at 11:00 A.M., through 8/27/21 showed: - The facility's front parking lot with large areas of missing concrete and only gravel. Some areas measured approximately three feet wide in some spots and at least 6 feet long. The concrete had deteriorated from around the joints in the concrete. - Window sill outside rotted on all windows on the west front outside of the building. The two located the furthest from the facility's entrance actually had wood missing, crumbling when touched and peeling away. - Egress doors located on the end of the 100 and 200 halls each had two windows, one large and one small, on the side of the door. The windows had metal frames around them had rusted with the worst places being the metal frame separating the large window from the small window. 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 observations, interviews and record review, the facility failed to promote an environment respectful of the rights of each resident to make choices about significant aspects of their lives when staff did not honor a resident's preferences for bedtime which affected one of 12 sampled residents (Resident #26) and failed to honor a resident's preference for smoking which affected Resident #5. The facility census was 30. Review of the facility's smoking policy for employees, revised May, 2019, showed, in part: - It is the policy of this facility to provide our employees with as near a smoke-free environment as possible and to ensure safe smoking practices for those who smoke; - Residents and visitors: While this policy applies primarily to our staff, certain smoking restrictions apply to our residents and visitors. Residents and visitors are not permitted to smoke in any area that is not designated as a smoking area. Smoking is not permitted in resident rooms. The facility did not provide a smoking policy…

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 interviews, the facility failed to ensure they notified one of 12 sampled residents' (Resident #26) family when the resident fell. The facility's census was 30. Review of the facility's Falls-Clinical Protocol policy, revised March 2018, showed the plan did not direct staff when or who to notify when the resident falls. Review of the Resident Incident Review form, part of the facility's electronic medical record program, showed staff should document in the Actions Taken section of the form the name of the physician and family members they notified of the fall, the date/time contact initiated and the date/time responded. Staff also had a line on the form to put the name of the person completing the form. Review of Resident #26's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/5/21, showed: - A Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment; - Independent with bed mobility,…

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 ensure staff notified residents and/or their representative when there was a change in one sampled resident's (Resident #9) covered services when he/she was discharged from skilled nursing services and remained in the facility. The facility census was 30. The facility did not provide a policy for providing Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN). Review of information provided surrounding Resident #9's discharge from skilled nursing services showed: - Episode start date of skilled nursing services: 5/28/21; - The resident's last covered date of skilled nursing services was 7/15/21; - The facility initiated the resident's discharge from physical therapy and the resident remained in the facility. - Staff did not provide or have the resident or his/her representative sign the SNF ABN to notify them of what services were no longer covered by Medicare if the resident continued to receive them. During an interview on 8/27/21 at 3:00 P.M., the administrator said she did not realize there 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 observation, interview, and record review, the facility failed to ensure that an entrapment assessment was done prior to installing quarter side rails on the both sides of the resident's bed, and failed to do quarterly entrapment assessments. This affected one resident (Resident #7) of 12 sampled residents. The facility census was 30. 1. Review of the Bed Safety Policy dated 2001 and revised December 2007 showed: -To prevent deaths/injuries from the bed and related equipment, the facility shall: a. Maintenance staff shall inspect all of the resident beds and related equipment to identify risks and problems including potential entrapment risks. b. Review that gaps within the bed system are within the dimension regulation. The resident's weight, movement and bed position shall be considered as well. c. Ensure that the bed side rails are installed properly per the manufacturer guidelines to ensure proper fit. - The maintenance department shall provide a copy of the inspections to the Administrator and report to the Quality Assurance (QA) committee for appropriate action. - If…

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 they used residents' comprehensive, person-centered assessment to develop and update residents' care plans to ensure the plan directed staff on how to provide care for each resident which affected one of 12 sampled residents (Resident #234). The facility census was 30. Review of the facility's Care Plans, Comprehensive Person-Center policy, revised December 2016, showed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. - Each resident's comprehensive person-centered care plan will be consistent with the resident's rights to participate in the development and implementation of his/her plan of care. - Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. - The Interdisciplinary Team (IDT) must…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure that the physician order for eye drops matched the mediation label on the eye drops. This affected one resident (Resident #5) out of 12 sampled residents. The facility census was 30. Review of the medication administration policy dated 2001 and revised April 2019 said: - Medications are administered according to the prescribers' orders, including any required timeframe. - Medication errors are documented, reported, and reviewed by the Quality Assurance and Performance Improvement (QAPI) committee to inform process changes and/or the need for additional staff training. - The person administering the medication will check the label 3 times to verify the right resident, right medication, right dosage, right time, and right method/route of administration before giving the medication. Review of the policy for installation of eye drops dated 2001 and revised January 2014 said: - The person administering the eye drops is to wash his/her…

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 documentation of the pharmacist's recommendations for two of 12 sampled residents, Resident #5 and Resident #21. The facility census was 30. The facility did not provide a policy for drug regimen reviews. 1. Review of Resident #5's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 8/10/21, showed: - Cognitive skills intact; - Limited assistance of one staff for bed mobility, transfers, dressing and personal hygiene; - Upper and lower extremity impaired on both sides; - Had seven insulin injections in the last seven days; - Had seven antidepressants in the last seven days; - Had seven diuretics in the last seven days; - Had seven opiods in the last seven days; - Diagnoses included anemia ( (low number of red blood cells to carry adequate oxygen to your body's tissues), diabetes mellitus, low back pain, hemiparesis (muscle weakness or paralysis on one side of the body). Review of the resident's…

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

Based on observations, interviews and record review, the facility failed to ensure staff administered medications with a medication error rate of less than 5%. Facility staff made two medication errors out of 25 opportunities for error, a medication error rate of 8%, which affected two of 12 sampled residents, (Resident #5 and #27). The facility census was 30. Review of the facility's administering medications, revised April 2019, showed, in part: - Medications are administered in a safe and timely manner, and as prescribed. Review of the facility's administering topical medications, revised October 2010, showed, in part: - The purpose of this procedure is to provide guidelines for the safe administration of topical medications; - Prepare the correct dose of medication; - Apply medication: paste, cream, ointment or lotion:removed tongue blade from sterile wrapper. Place medication on the tongue blade and transfer to gloved hands. Warm the medication in gloved hands and apply gently to the skin. 1. Review of Resident #5's physician order sheet (POS), dated August 2021, 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.