Delmar Gardens Of O'fallon

Based on observation, interview and record review, the facility failed to prepare and serve food at a safe and appetizing temperature and to conserve the flavor of food items. The facility census was 149. 1. Review of the facility's undated policy, Monitoring Food Temperatures for Meal Service, showed the following: -Food temperatures will be monitored daily to prevent food borne illness and ensure foods are served at palatable temperatures; -The temperature for each food item will be recorded on the Food Temperature Log. Foods that required corrective action (such as reheating), will have the new temperature recorded with a circle around it next to the original temperature; -If the serving/holding temperature of a hot food is not at 135 degrees Fahrenheit (F) or higher when checked prior to meal service, the item will be reheated to at least 165 degrees F for a minimum of 15 seconds; -If the serving/holding temperature of a cold food item or beverage is not at 41 degrees F or below (for less than four hours in duration) when checked prior to meal service, the item will be chilled…

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

Based on observation, interview, and record review, the facility failed to ensure residents, including those with a physician's order for a mechanical soft diet, received food items with the proper texture to allow for foods to be easily swallowed. The facility census was 149. 1. Review of the facility policy, admission Diet Orders, effective June 2021, showed the following: -Purpose: To ensure each resident has a diet order prescribed by the physician and documented in the medical health record. The safest diet for each resident will be ordered; -All diet orders will be reviewed upon admission by the charge nurse to assure that they conform to the language of the facility offered diets; -If there is a particular dysphagia diet that is not offered by the facility, the diet should be downgraded to a diet used in the community until a speech therapist can evaluate the resident; -A speech therapist consult should be initiated for all residents on texture modified diets for the evaluation of the appropriate diet for safe consumption by the resident; -Samples of appropriate diet…

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 appropriate infection control and prevention procedures while providing care to 12 residents, (Resident #11, 58, 59, 74, 77, 78, 87, 89, 120, 121, 309 and 606), in a review of 35 sampled residents. Staff failed to use appropriate hand washing and gloving techniques while providing care, failed to wear appropriate personal protective equipment (PPE), failed to utilize enhanced barrier precautions (EBP) during care and failed to ensure proper infection control was utilized for respiratory care supplies. The facility census was 149. Review of the facility policy, Enhanced Barrier Precautions (EBP), revised 3/2024, showed the following: -Purpose was to reduce the spread of multi-drug resistant organisms (MDRO); -EBP was indicated for residents with any of the following: Infection or colonization with a Centers for Disease Control (CDC)-targeted MDRO when contact precautions do not otherwise apply; or, wounds and/or indwelling medical…

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 the pneumococcal vaccine (a vaccine that can protect against pneumococcal disease) as indicated by the current Centers for Disease Control and Prevention (CDC) guidelines for three residents (Residents #26, #94 and #403), in a review of 35 sampled residents. The facility census was 149. Review of the facility policy Pneumococcal Vaccination of Residents dated 2/2022 showed the following: Purpose: -To reduce morbidity and mortality from pneumococcal disease by vaccinating all adults who meet the criteria established by the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP); Policy: -Upon admission, residents will be assessed for need of pneumococcal vaccination. ACIP recommends a single dose of PCV20 (Prevnar 20) for adults aged > 65 years who have not previously received the pneumococcal conjugate vaccine or whose vaccination history is unknown. For adults aged 19-64 years with certain underlying…

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 three residents (Resident #80 and #403) in a review of 35 sampled residents, were treated in a manner to maintain dignity and respect. The facility census was 149. Review of the facility's undated Residents' Rights policy, showed the following: Dignity and Respect: -Your right to be treated with dignity and respect is the foundation on which all other resident rights and responsibilities are based. You have the right to expect that we will: 1. Treat you as an individual and assist you in getting the most out of the programs and services we offer; 4. Provide safeguards against any kinds of harsh or abusive treatment. 1. Review of Resident #403's care plan, dated 4/29/24, showed the following: -The resident is at risk for falls due to weakness; -The resident has a deficit in mobility related to weakness, current weight bearing status is weight bearing as tolerated, one person transfer; -The resident has a deficit in activities 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, interview, and record review, the facility failed to ensure one resident (Resident #72), a resident with identified history of ingesting non-food items such as Styrofoam, in a review of 35 sampled residents, was served food on Styrofoam. Additionally, the facility failed to ensure staff safely transferred one additional resident, (Resident #306), with a gait belt, when staff assisted and lifted the resident for transfer by placing their hands underneath the resident's arms during the transfer. The facility census was 149. Review of the facility policy for Gait Belt Use, dated 7/2015, showed: -Purpose: to provide control and balance of a resident that required physical assistance for transfers and gait; -Gait belts should be used with all residents that require physical lifting assistance for transfers and/or ambulation; -Wrap the gait belt around the resident's waist and pull the strap through the buckle to tighten; -Make sure you can slide your open (flat) hand between the belt and the resident; -Face the resident when assisting to standing potion and place…

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 provide food in a form as ordered by the physician, monitor weights, notify the physician of the refusal of nutritional supplements and weights for two residents with significant weight loss, (Resident #59 and #305), in a review of 35 sampled residents. The facility census was 149. Review of the facility policy for Weight Monitoring, dated 11/2018, showed: -Purpose: to obtain accurate weight of each resident and maintain control of weight changes; -Residents are weighed on admission, weekly for the first four weeks and monthly thereafter, unless otherwise ordered by nursing order or the attending physician; -Residents are weighed upon admission and on a weekly basis for the first four weeks to establish a baseline weight; -Any resident with a weight gain/loss of five pounds will be re-weighed within 24 hours; -Weight reports will be monitored by the Charge Nurses, Registered Dietician (RD)/Dining Services Director and Director 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 and interview, the facility failed to ensure equipment was maintained in good repair and safe operating condition so as not present a hazard to staff, residents, or visitors. The facility census was 149. Observation on 5/8/24 at 10:44 A.M., in the kitchen, showed the power cord of the food processor was frayed at the connection to the machine and was missing part of the cord's protective coating in an approximate one-inch long section. Observation on 5/7/24 at 12:54 P.M., in the 700 servery, showed the refrigerator compartment of a combination refrigerator/freezer unit was not working. The temperature on the unit read 105 degrees Fahrenheit. The door opened freely and felt warm inside the compartment. No food items were located in the compartment and there was no sign posted on the unit indicating the compartment was not working nor instructing staff, residents, or visitors to not put food items in the compartment for cooling. During an interview on 5/7/24 at 12:54 P.M., Dietary Aide I, confirmed the refrigerator compartment of the 700 servery combination…

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 consistently follow their policy to complete skin assessments to identify areas of concern to ensure timely implementation of interventions and treatment for one sampled resident, (Resident #2) of six sampled residents. The facility census was 167. Review of the facility policy for Pressure Ulcer Care and Documentation dated 7/21 showed: -Purpose: To prevent pressure injuries and/or prevent deterioration of existing pressure injuries: -Causes in part: impaired circulation, wrinkles,lumps in bedding and chairs; fragile skin caused by the aging process, pressure on bony prominence for example heels; -Warning signs: observe daily for the following signs of potential pressure injury signs and report accordingly: redness or a darker, beeper bruise-like color, heat, tenderness, pain or discomfort, cracks in the skin, excessive dryness, sores, cuts or abrasion. Report any changes of condition to the charge nurse; -Prevention: frequent applications of lotion,…

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 kitchen was maintained in a sanitary manner to prevent the potential spread of food borne illness to 135 residents who resided in the facility and were able to consume meals. Concerns included: ensuring expired items were disposed of timely, proper dating and labeling of all food items, and providing proper training to all staff handling food. Findings include: Review of the facility's policy titled, Food Storage (Dry/Refrigerated/Frozen), 2014 Edition, indicated All food items will be labeled. The label must include the name of the food and the date consumed or discarded .discard food that has based the expiration date .keep potentially hazardous foods out of the temperature danger zone (41 degrees Fahrenheit (F) - 135 degrees F) .Set refrigerators to the proper temperature .Keep freezer at a temperature that ensures products will remain frozen. Review of the facility's policy titled, Labeling/Dating Foods (Date Marking), 2014 Edition indicated All foods stored will be properly…

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 maintain ceiling vents free from a buildup of dust and failed to maintain ceilings in a clean condition. The facility census was 136. 1. Observations on 10/25/22 between 11:30 A.M. and 5:00 P.M., during the life safety code tour of the facility, showed the following: -In the 100 hall soiled utility room, two 4 inch by 4 inch vents and a 6 inch by 6 inch vent were covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER], the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER]B, the exhaust vent in the bathroom was covered with a thick layer of dust; -In resident room [ROOM NUMBER]A,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the Resident Assessment Instrument (RAI) Manual, and interviews, the facility failed to timely complete and submit quarterly Minimum Data Set (MDS) assessments for six (Residents (R) R5, R10, R24, R19, R6, R7) out of 41 sample residents. This deficiency had the potential of missed opportunities for care and services due to incomplete assessments done in a timely manner. Findings include: Review of the Resident Assessment Instrument (RAI) Manual, dated 10/01/19, indicated, . The RAI helps nursing home staff look at residents holistically-as individuals for whom quality of life and quality of care are mutually significant and necessary. Interdisciplinary use of the RAI promotes this emphasis on quality of care and quality of life. Nursing homes have found that involving disciplines such as dietary, social work, physical therapy, occupational therapy, speech language pathology, pharmacy, and activities in the RAI process has fostered a more holistic approach to resident care and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed ensure one of three residents (Resident (R)1) reviewed for activities was provided an activity calendar and invited to attend activities. Findings include: Review of a Face Sheet located in R1's electronic medical record (EMR) under the Face Sheet tab indicated the resident was admitted to the facility on [DATE] with a primary diagnosis of chronic atrial fibrillation (irregular heartbeat), major depressive disorder, and anxiety. Review of R1's admission Care Plan dated 10/02/22, located in the EMR under the Care Plan tab included interventions to allow the resident to verbalize interest in activities, discuss previous activity experiences, furnish resident with current activity calendar, inform and escort to activities of interest, inform staff to make frequent visits on 1st and 2nd shifts, orient to facility and activity department, provide in room leisure interest as requested and/or needed .Resident has indicated the following leisure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to ensure behavioral health services were provided for one of one sampled Resident (R)1 reviewed for behavioral health. Findings include: Review of the facility's policy titled Behaviors Using Person-Centered Care, Accommodating, revised 02/2021 related to problem behaviors stated, behaviors- disruptive to community's routine, creates more work, upsets other residents; root cause analysis is recommended, .majority of behavior symptoms result from cognitive and functional impairments of dementia, unmet psychosocial needs, sensory deprivation, boredom, loneliness .non-pharmacological interventions . Review of the Face Sheet located in R1's electronic medical record (EMR) under the Face Sheet tab indicated the resident was admitted to the facility on [DATE] with a primary diagnosis of chronic atrial fibrillation (irregular heartbeat), major depressive disorder, and anxiety. Review of R1's physician Orders dated 10/01/22 located…

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 facility policy review, the facility failed to ensure medication, medication carts, and treatments cart were secured when unattended. This had the potential for medications to becaome diverted or for a cogntively impaired resident to potentially take the medications. Findings include: Record review of policy titled Corum Health Services Pharmacy Policy/Procedures Storage of Drugs updated 12/21, provided by the facility, reflects in part, Compartments and areas containing drugs are locked when not in use or when left unattended. Such areas include drawers, cabinets, rooms, refrigerators, carts, and boxes. Observation on 10/18/22 at 4:30 PM of the 600-hall medication cart revealed the cart unlocked and unattended between rooms 605-607. Interview in 10/18/22 at 4:32 PM with Certified Medication Technician (CMT)1 confirmed the cart was unlocked and should not have been. CMT1 confirmed she was in a resident's room and had left the cart unlocked. She stated the facility 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 observation, interview, and record review, the facility failed to maintain the walk-in freezer at 0 degrees Fahrenheit (F) or below to keep items frozen solid; failed to ensure food items were labeled, dated, covered and discarded when expired; and failed to maintain an appropriate air gap on two ice machines. The total facility census was 183 with a certified census of 128. 1. Record review of the Refrigerator/Freezer Temperature Log sheet for the walk-in freezer located in the main kitchen, dated October 2019, showed the following morning and evening freezer temperatures: -October 1: 6 degrees F and 5 degrees F; -October 2: 14 degrees F and 6 degrees F; -October 3: 17 degrees F and 8 degrees F; -October 4: blank and 4 degrees F; -October 5: blank and 3 degrees F; -October 6: blank and 1 degree F. Observation on 10/07/19 at 11:03 A.M. showed the walk-in freezer in the main facility kitchen had an exterior digital temperature display of the internal temperature that read 12 degrees F. The thermometer…

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 two residents (Resident #28 and #68), in a review of 25 sampled residents, and four additional residents (Residents #32, #115, #602 and #603) were treated with dignity and respect. The total facility census was 183 with a certified census of 128. 1. Review of the facility's undated policy, Resident Rights, showed the following: -Your right to be treated with dignity and respect is the foundation on which all other resident rights and responsibilities are based; -You will have the right to expect that we will treat you as an individual and assist you in getting the most out of the programs and services we offer. 2. During a group interview on 10/8/19 at 3:32 P.M., residents said the following: -Resident #115 said his/her table mate had to go to the bathroom and staff told this resident to go in his/her pants; -Resident #32 said he/she had an accident (soiled himself/herself) waiting to go to the bathroom. He/She apologized to the staff for doing this but he/she shouldn't have had to apologize. It made…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to create an environment that was respectful of the rights of each resident to make choices about aspects of their lives that were significant to them for five residents (Residents #44, #51, #62, #424, and #426), in a review of 25 sampled residents, and for three additional residents (Residents #2, #58, and #601), when the facility failed to honor residents' preferences for time to awaken. The total facility census was 183 with a certified census of 128. 1. Review of the facility Resident [NAME] of Rights provided in the admission Agreement showed the following: -You are entitled to take part in planning your care and in being informed of all aspects of you care; -You may refuse any treatment you do not want. 2. Review of the facility policy, dated June 2002, titled Staff Assignments, showed the following: -The facility was to provide person-centered/directed care; -Find out resident's preferences and routines; -Record and discuss treatment…

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 ensure facility staff provided five of 25 sampled residents (Resident #28, #44, #16, #426, and #51) and one additional resident (Resident #601), who were unable to perform their own activities of daily living, the necessary care and services to maintain good personal hygiene and prevent body odor. The total facility census was 183 with a certified census of 128. 1. Review of the facility's policy, Perineal Care, dated 01/2017, showed the following: -Purpose: to establish a routine for providing perineal care, which will cleanse, prevent skin breakdown, prevent infection and prevent odors; -All residents will receive perineal care, as needed, in the morning before breakfast, every evening with evening care at bedtime, as needed after bowel movement or urination, and each time the resident is incontinent; -FEMALE: Make a mitten with the washcloth, wet and apply soap or peri-wash. Wash perineal area thoroughly. Separate the labia and wash…

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 employ appropriate methods for repositioning for three additional residents (Residents #2, #600 and #601), when staff lifted and repositioned the residents under their arms and by the waist of the resident's pants. The facility also failed to ensure staff consistently implemented interventions identified to prevent falls for three residents (Residents #93, #77 and #426), in a review of 25 sampled residents. The total facility census was 183 with a certified census of 128. 1. Review of the Nurse Assistant in Long-Term Care Facility Student Reference, 2001 revision, Lesson Plan 3, Unit VII, titled Transferring Residents, showed: -The gait belt is a special belt that is placed around the resident's waist and provides the nurse assistant. with a handle to hold onto for those who require assistance during transfers, ambulation, or repositioning in the chair; -The purposes of using a gait belt is to ensure optimum safety and comfort for 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 maintain urinary drainage bags (bag attached to a catheter to collect urine) below the level of the bladder and failed to keep catheter tubing and urinary drainage bags off of the floor or other surfaces for three sampled resident (Residents #51, #62, and #83), and for one additional resident (Resident #602). The total facility census was 183 with a certified census of 128. 1. Review of the facility policy, Catheter Care, dated October 2008 and last revised December 2009, showed the following: -Attach catheter bag to bed frame only; -Never lift bag above bladder level (source of infection). 2. Review of the Nurse Assistant in a Long-Term Care Facility, Student Reference, 2001 Revision, showed the following: -The bladder is considered sterile. The catheter, drainage tubing, and bag are a sterile system; -Drainage tubing/bags must not touch the floor; always hook to unmovable part of the bed frame or chair; -When transferring residents from…

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 sufficient nursing staff to meet residents' needs for five residents (Residents #51, #425, #426, #62, and #93), in a review of 25 sampled residents and six additional residents (Resident #2, #58, #601, #603, #800 and #801). The total facility census was 183 with a certified census of 128. 1. Review of the facility assessment, reviewed with the Quality Assessment and Assurance (QAA)/Quality Assurance and Performance Improvement Plan Review (QAPI) committee, dated 9/11/19, showed: -There were 132 residents who required assistance from one to two staff with dressing, and 14 residents who were totally dependent on staff; -There were 115 residents who required assistance from one to two staff with bathing, and 38 residents who were totally dependent on staff; -There were 58 residents who required assistance from one to two staff with eating, and ten residents who were totally dependent on staff; -There were 118 residents who required…

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

Based on observation, interview, and record review, the facility failed to ensure staff served residents on a pureed diet the correct portion sizes of protein, and failed to serve residents on a regular diet full serving scoops of food items according to the spreadsheet menu. The total facility census was 183 with a certified census of 128. 1. Record review of the Order Report by Category, dated 10/7/19, showed three residents had a physician's order for a pureed diet. Review of the Diet Spreadsheet, Week 5, showed staff was to serve residents on a pureed diet a #6 serving (2/3 cup) of pureed Philly sandwich with bread. Observation on 10/7/19 at 12:19 P.M. of the 200 Hall servery steam table showed a #8 scoop (1/2 cup) sat in the pan of pureed Philly sandwich with bread. Observation on 10/07/19 at 12:20 P.M. in the 200 Hall servery showed Licensed Practical Nurse (LPN) Y plated four trays for residents on pureed diets. He/She used the #8 scoop to serve the pureed Philly sandwich. He/She did not serve a full #8 scoop to the residents or use a #6 scoop as directed by the spreadsheet…

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 evening snacks for two residents (Resident #93 and #96), in a review of 25 sampled residents, and for four additional residents (Residents #23, #32, #60, and #115) who participated in a group interview. The total facility census was 183 and the certified census was 128. 1. Review of the facility policy Snack Availability from the Family Dining Services Policy and Procedure Manual, dated 2014, showed the following: -Evening snacks were offered to all residents unless contraindicated by the physician's order; -A variety of snacks were offered to residents at bedtime. The variety will include snacks for various textures and therapeutic restrictions; -The food service department will be responsible for supplying, refilling and discarding unused snacks in the designated snack area(s). 2. During a group interview on 10/08/19 at 3:32 P.M., the residents said the following: -Resident #60 said he/she was diabetic and was not offered an evening snack. He/She would like to have an evening snack; -Residents #115, #93, #96,…

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 turn and reposition two additional residents (Residents #2 and #601), who were at risk for developing pressure ulcers. The total facility census was 183 with a certified census of 128. 1. Review of the Nurse Assistant in a Long-Term Care Facility, Student Reference, 2001 Revision, showed the following: -A pressure ulcer is an inflammation, sore, or lesion that develops over areas where the skin and tissue underneath are injured due to a lack of blood flow and oxygen supply to an area of the body; -This lack of circulation/blood flow and oxygen supply usually happens because of continuous pressure on the skin over a bony prominence resulting from the way or length of time a resident is positioned; pressure is the main cause; -Residents prone to forming pressure ulcers include elderly residents due to sluggish circulation, poor hydration, poor nutrition, and lack of exercise/mobility; paralyzed, thin, malnourished, obese, and incontinent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the medication regimen for one resident (Resident #53), in a review of 25 sampled residents, and for one additional resident (Resident #10), were free of unnecessary medications when their medical record lacked evidence the facility had a system to monitor the residents to ensure gradual dose reductions (GDR) were made in an effort to reduce or discontinue the medications. The facility also failed to ensure physicians orders for as needed (PRN) psychotropic medications were limited to 14 days as required except when an attending physician believed it was appropriate the PRN order be extended beyond 14 days, then the physician should document their rationale in the resident's medical record and indicate the duration for the as needed order. The total facility census was 183 with a certified census of 128. 1. Review of the facility policy, dated September 2013, titled Accommodating Behaviors Using Person-Centered Care, showed the following:…

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

Based on observation, interview, and record review, the facility failed to maintain and implement a comprehensive infection control program designed to help prevent the development and transmission of water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease). The total facility census was 183 with a certified census of 128. 1. Record review of the facility policy and plan, Water Management Program, showed the following: -The program was developed to identify hazardous conditions and take steps to minimize the growth and spread of Legionella and other waterborne pathogens in the facility water systems; -The program was a multi-step process that required continuous review and actions to be taken during regularly scheduled intervals to prevent Legionella and other bacteria from developing in the water delivery system; -Specific control measure locations were identified in the program and required an action, documentation of the action, and results; -The facility was to make sure the program was running as designed, was effective and that they documented…

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.