Aspire Senior Living Platte City

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure staff provided a written notice of transfer or discharge and bed hold which contained all of the required components for three of the 16 sampled residents (Resident #1, #13, and #33). The facility census was 65. Review of the facility's policy for Transfer and Discharge, dated 2021, showed: - It is the policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility except in limited situations when the health and safety of the individual or other residents are endangered; - The facility may initiate transfers or discharges in the following limited circumstances: the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; - Emergency transfers/discharges - initiated by the facility for medical reasons, or for the immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified); -…

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 appropriate treatment and services to maintain the strength and mobility for one resident (Resident #67) of 16 sampled residents. Facility census was 65. Review of the facility policy, Restorative Nursing Documentation, undated, showed: - The facility maintains complete, accurate, and organized documentation of restorative treatments and the response to those treatments; - The need for restorative nursing services will be documented in the medical record and indicated in the resident's care plan; - It will contain the problem, need or strength that is being addressed along with a measurable goal with target date; - It will contain specific interventions/treatments to be provided and the frequency and duration; - Treatment will be documented daily by the restorative aide to include treatment provided and number of minutes performed; - The resident's plan of care will be updated at routine intervals; Review of the facility policy, Activities of Daily Living (ADLs), undated, showed: - The facility will ensure 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 observations, interviews, and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff did not complete showers for three of the 16 sampled residents, (Resident #13, #46, and #64). The facility census was 65. Review of the facility's policy for Resident Rights, dated 2022, showed: - The resident has the right to a dignified existence, self-determination, and communication with and assess to persons and services inside and outside the facility; - The resident has the right to be informed of, and participate in his/her treatment. 1. Review of Resident #13's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/2/25 showed: - Cognitive skills intact; - Upper and lower extremities impaired on both sides; - Dependent on the assistance of staff for eating, toilet use, dressing, personal hygiene and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status when the facility did not timely identify, treat, and notify the primary physician of severe weight loss for two of 16 sampled residents (Resident #64 and #67). The facility census was 65. Review of facility policy, Weight Monitoring, undated, showed: - The newly recorded resident weight should be compared to the previous recorded weight. A significant change in weight is defined as: 5% change in 30 days, 7.5% change in 90 days, 10% change in 180 days; - The physician should be informed of a significant change in weight and may order nutritional interventions; - The physician should be encouraged to document the diagnosis or clinical conditions that may be contributing to the weight loss; -Meal consumption information should be recorded and may be referenced by the interdisciplinary care team; - The registered dietitian (RD) or dietary manager should be consulted to…

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

Refer to Event ID U31013 for additional information. Based on observation, interview, and record review, the facility failed to ensure two residents (Resident #3 and #2) were treated with dignity and respect when staff members were unnecessarily rough while providing care. This deficient practice affected two of 6 sampled residents. The facility census was 73.

Refer to Event ID U31013 for additional information. This deficiency is uncorrected. For previous examples, see the Statement of Deficiencies dated 03/03/2025. Based on interview and record review, the facility failed to report an injury of unknown origin to the Department of Health and Senior Services (DHSS) when Resident #1 sustained an open fracture (a bone break with an opening to the skin) to his/her right femur (upper leg bone). The Director of Nursing (DON) assessed the resident and did not report the injury of unknown origin to DHSS and did not immediately report to the Administrator. This deficient practice affected one of one sampled residents. The facility census was 73.

Refer to Event ID U31013 for further information. This deficiency is uncorrected. For previous examples, see the Statement of Deficiencies dated 03/03/2025. Based on interview and record review, the facility failed to initiate an investigation into an injury of unknown origin when Resident #1 sustained an open fracture (a bone break with a skin opening) to his/her right femur (upper leg bone). The Director of Nursing (DON) assessed the resident and did not initiate an investigation to determine the cause of the injury. This deficient practice affected one of one sampled residents. The facility census was 73.

Based on interview and record review the facility failed to protect one resident (Resident #4) of 6 sampled residents, right to be free from verbal and physical abuse when Certified Medication Technician (CMT) A called the resident derogatory names based on his/her body type and abilities and roughly pushed the resident's wheelchair forward. The facility census was 66. Review of the facility policy titled, Abuse Prevention Program, dated 1/20/25 showed: -It is the policy of this facility to provide protections for the health, welfare and rights of each resident; -Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment resulting in physical harm, pain, or mental anguish. Instance of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology; -Verbal abuse is defined as the use of oral, written, or gestured communication or sounds that willfully…

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.

A revisit was completed and the facility was found to have continued non-compliance. Refer to Event ID U31012 for federal and state deficiencies cited as a result of this complaint investigation. Based on interview and record review, the facility failed to report an injury of unknown origin, when the facility staff became aware on 2/27/25 that one resident (Resident #1) had a right leg femur fracture. The facility census was 67.

Refer to Event ID U31012 Based on interview and record review, the facility failed to complete a thorough investigation when one resident (Resident #1) sustained a femur fracture of unknown origin and failed to maintain documentation that an alleged violation was thoroughly investigated. The facility census was 67.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two residents (Resident #3 and #2) were treated with dignity and respect when staff members were unnecessarily rough while providing care. This deficient practice affected two of 6 sampled residents. The facility census was 73. Review of the facility policy titled Resident Rights, dated 1/30/24, showed the facility staff will treat the resident with respect and dignity. Review of the facility policy titled Perineal Care, dated 1/20/25, showed: - The purpose of the policy was to ensure the residents receive safe and respectful perineal care; - The staff are to uphold the resident's dignity with professional standard in long-term care; - All residents who require assistance with perineal care will be provided with appropriate and person-centered care that promotes their comfort and dignity. 1. Review of Resident #3 admission MDS, dated [DATE], showed: -A BIMS of 15 indicated no cognitive loss; -Dependent on staff for ADLs; -Diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to protect Resident #2's right to be free from sexual abuse by Resident #1, when Resident #1 was observed by staff sitting next to Resident #2, with his/her hand down the front of Resident #2's pants. The facility census was 63. Review of the facility's undated Abuse Prevention Program policy showed: -Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment resulting in physical harm, pain, or mental anguish. Instance of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology; -Sexual abuse is defined as non-consensual sexual contact of any type with a resident; -The purpose of this policy is to protect the residents in this facility from abuse, neglect, misappropriation of resident property, corporal…

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

Based on interview and record review, the facility failed to report an injury of unknown origin, when the facility staff became aware on 2/27/25 that one resident (Resident #1) had a right leg femur fracture. The facility census was 67. Review of facility policy, Abuse, Neglect, and Exploitation, revised 1/17/25, showed: -Reporting of all alleged violations to the administrator, state agency, adult protective services, and to all other required agencies within specified time frames: -Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or -Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. -The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. 1. Review of Resident #1's Quarterly Minimum Data set (MDS), 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.

Based on interview and record review, the facility failed to complete a thorough investigation when one resident (Resident #1) sustained a femur fracture of unknown origin and failed to maintain documentation that an alleged violation was thoroughly investigated. The facility census was 67. Review of facility policy, Abuse, Neglect, and Exploitation, revised 1/17/25, showed: -Possible indicators of abuse included: physical injury of a resident, of unknown source; -An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. -Written procedures for investigations include: -Identifying staff responsible for the investigation; -Exercising caution in handling evidence that could be used in a criminal investigation; -Investigating different types of alleged violations; -Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; -Focusing investigation on determining if abuse, neglect, exploitation,…

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 ensure staff served food to the residents that was palatable, attractive, and served at a safe and appetizing temperature to the residents when hot food was not served at an appetizing temperature to seven of the 17 sampled residents (Resident #8, #2, #58, #27, #56, #55, and #212). The facility census was 66. Review of facility policy, food and drink, dated 1/30/24, showed: -Food prepared by methods that provides nutritive value, flavor and appearance; -Food and drink that is palatable, attractive, and served at a safe and appetizing temperature Review of food safety policy, dated 1/30/24, showed: -Facility must store, prepare, distribute, and serve food in accordance with professional standards for food safety. -Ensuring safe food handling once food is brought to facility, including safe temperatures of food and handling of leftovers Review of facility policy, food safety, undated, showed: Holding Hot foods: -To ensure safety, hot foods must be held at…

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 store, prepare, and serve food in accordance with professional standards of food service safety when staff with facial hair failed to wear beard coverings, failed to wash hands, failed to date and label all foods, failed to have thermometers in refrigerator and freezer, and failed to maintain a clean and sanitary kitchen. This had the potential to impact all residents in the facility. The facility census was 66 residents. Review of facility policy, food and drink, undated, showed: -Purpose: ensure that the nutritive value of food is not compromised or destroyed because of prolonged: -Food storage, light, and air exposure; -Cooking of foods in a large volume of water or; -Holding on a steam table. -Procedure: -Each resident receives and the facility provides - -Food prepared by methods that provides nutritive value, flavor, and appearance. -Food and drink that is palatable, attractive, and served at a safe and appetizing temperature. -Food is prepared in a form designed to meet individual needs. -Food that…

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 Based on observations, interviews and record review, the facility failed to treat each resident with respect and dignity and failed to provide care for each resident in a manner and in an environment that promoted enhancement in their quality of life when staff failed to knock on resident doors prior to entering their room and failed to announce themselves to (Resident #2 and #8), Staff left the bedroom door to the hallway open while providing peri-care to one resident (Resident #35). Additionally, staff failed to answer one resident's call light in timely manner resulting in that resident being incontinent of urine (Resident #21). This affected four residents out of the 17 sampled residents. The facility census was 66. Review of facility policy, Resident Rights, dated 1/30/24, showed: -The facility will treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life and recognizes each…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review, the facility failed to create an environment respectful of the rights of a resident to make choices about aspects of his/her life that are significant to them, when the facility failed to allow two out of seventeen sampled residents to go outside unsupervised (Resident #45 and #212). The facility census was 66. Review of the facility's Resident Rights policy, dated 1/30/24., showed: -Residents do not leave their individual personalities or basic human rights behind when they move to a long-term care facility. The facility will treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life and recognizes each resident's individuality. -Resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his/her rights and to be supported by the facility and the exercise of those rights. -To receive…

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

Based on record review and interview, the facility failed to maintain a surety bond sufficient to ensure the protection of resident funds. The facility census was . Review of the facility maintained Resident Trust Bank Statements for the period 05/2023 through 05/2024, showed an average monthly balance of $27,000.00. Review on 05/07/24, of the Department of Health and Senior Services approved bond list showed the facility had a $1,000.00 approved bond, making the bond insufficient by $22,000.00. During an interview on 05/07/24 at 10:42 A.M., the Business Office Manager said the facility had changed ownership recently and was unaware the bond had not been reassessed since the new company had taken control. During an interview on 05/07/24 at 3:44 P.M., the Business Office Manager said she would expect the bond to be sufficient to cover the resident funds.

Based on observation and interview, the facility failed to protect the resident rights when the facility did not provide accessible information regarding the State Long Term Care Ombudsman program and the State Survey Agency in a location that was readily available and could be read by residents in the facility without assistance. The facility census was 66. Review of facility policy, resident rights, undated, showed: -The resident has the right to receive a list of the names, addresses (mail and email) and telephone numbers of all pertinent state regulatory and informational agencies, resident advocacy groups such as the State Survey Agency, the State licensure office, the State Long-Term Care ombudsman program, the protection and advocacy agency, adult protective services, the local contact agency for information about returning to the community and the Medicaid Fraud Control Unit. The resident must also receive a statement that he/she may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulations, including…

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 interviews and record review, the facility failed to clarify the code status (whether the resident wished to have cardio-pulmonary resuscitation- CPR) of two of the 17 sampled residents, (Resident #45 and #214), and failed to ensure Resident #16's Durable Power of Attorney (DPOA) for Health Care Decisions was invoked (activated by verifying incapacity of the resident to make decisions) by two physicians. The facility census was 66. Review of the facility's policy for living will/advance directives/life-sustaining treatment orders, dated [DATE], showed, in part: - The purpose is to ensure resident rights are protected when Advance Directives have been executed: - Residents will be given the option of completing a Living Will (a type of advance directive that states the specific types of medical care that a person wishes to receive if that person is no longer able to make medical decisions because of a terminal illness or being permanently unconscious) or Advance Directive if they have not already done…

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 they maintained a safe, clean, comfortable homelike environment for the residents when staff did not keep all areas of the facility clean and safe; and failed to maintain comfortable temperatures in the common areas of the building between 71 and 81 degrees Fahrenheit (F). Additionally, the facility failed to ensure they provided a sufficient amount of bed linens, towels and wash cloths. The facility census was 66. Review of the facility policy Cleaning Resident Rooms dated 1/30/24 showed: -Ensure rooms are clean and sanitary. The facility did not provide a policy on cleaning hallways, general areas or common areas of the facility. The facility did not provide a policy on Homelike Environment. The facility did not provide a policy for the amount of linens the facility should have on hand. 1. Observations beginning on 5/06/24 at 10:03 A.M., showed: -the ceiling vent, at room C111, had cobwebs and thick coating of dust on the grates; -C hall handrails had chips in the paint and exposed wood; -Ceiling…

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 observation, the facility failed to ensure residents knew how to file a grievance. This deficient practice had the potential to affect any resident wanting to file a grievance. The facility census was 66. Review of facility policy, resident rights, undated, showed a resident has the right to voice grievances to this facility or other agency concerning treatment, care, behavior of staff and/or other residents as well as other concerns about his/her stay without discrimination or reprisal. The resident has the right to information on how to file a grievance or complaint as well as to the prompt resolution of grievances. 1. During a group meeting on 5/7/24 at 1:32 P.M., thirteen of thirteen residents said that they did not know how to file a formal grievance or who the grievance officer in the facility was. Observation on 5/9/24 at 10:51 A.M., showed a red folder hanging on the wall at four feet, which is inaccessible to residents in wheelchair position. This folder contained blank grievance forms with no area or information identified of where grievance forms…

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

Based on record review and interview, the facility staff failed to check the Certified Nurse Assistant (CNA) Registry for all staff to ensure they did not have a Federal Indicator (a marker given by the federal government to individuals who have committed abuse/neglect). This affected three of ten sampled staff (Certified Medication Technician A, Dietary Aide C, and Licensed Practical Nurse C). The facility census was 66. Review of facility Policy, Abuse and Neglect, dated 1/30/24, showed: -Employee background checks and employment history collection will be done before hire. The facility will not knowingly employ any individual who had been found guilty of abusing, neglecting, exploiting, misappropriating, or mistreating individuals. -The abuse prevention program provides polices and procedures that govern, as a minimum: -Conducting employee background checks. 1. Review of Certified Medication Technician (CMT) A's employee file., showed: - Employee hired on 12/26/23; -No Family Care Registry check had been completed; -No Employee Disqualification List (EDL) check had been…

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

Based on interview and record review, the facility failed to ensure staff provided a written notice of transfer or discharge to residents or their responsible parties that included the reason for the transfer, in writing and in a language they understood. The notice should have included the effective date of discharge or transfer, the location to which the resident would be transferred or discharged , and information regarding the resident's appeal rights, including how to file an appeal or obtain assistance in completing and submitting it. The facility also failed to notify the State Long-Term Care Ombudsman of the transfers and discharges. This affected two of 17 sampled residents, (Resident #14 and #27). The facility census was 66. The facility did not provide a policy for transfer/discharge of a resident. 1. Review of Resident #27's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/8/24 showed: - cognitive skills moderately impaired; - upper and lower extremities impaired on one side; - dependent on staff for toilet…

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 interviews and record review, the facility failed to ensure staff informed the residents and their family/legal representatives of the bed hold policy at the time of the transfer/discharge to the hospital for two of 17 sampled residents, (Resident #14 and #27). The facility census was 66. The facility did not provide a bed hold policy. 1. Review of Resident #27's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/8/24 showed: - cognitive skills moderately impaired; - upper and lower extremities impaired on one side; - dependent on staff for toilet use and transfers; - frequently incontinent of urine; - always incontinent of bowel; - diagnoses including stroke, Alzheimer's disease ( brain disorder that slowly destroys memory and thinking skills and the ability to carry out the simplest tasks), dementia (the inability to think), anxiety, depression, and hemiplegia ( paralysis affecting one side of the body). Review of the resident's 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 observation, interview's and record review, the facility failed to complete a Minimum Data Set (MDS) a federally mandated assessment completed by the facility staff within the required time frames, upon the resident's admission for 3 of 17 sampled resident's (Resident #214, #216, and #212). The facility census was 66. The facility did not provide a policy regarding comprehensive assessments. Review of facility policy, Medically Related Social Services, dated 1/30/24, showed: -Facility must provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. -Social services services may include identifying and seeking ways to support resident's individual needs through the assessment and care planning process. 1. Review of Resident #214's Face Sheet, dated 5/7/24, showed: -He/She admitted to facility on 4/19/24; -Diagnoses included rheumatoid arthritis and generalized muscle weakness. Review of MDS showed resident did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized care plans, to address the specific needs of the residents, for three of 16 sampled residents (Residents #162, #45, #216, and #214). The census was 66. Review of the facility provided policy, Comprehensive Care Plan, dated 1/30/24 showed: -Each resident will have a person centered comprehensive care plan developed and implemented to meet his/her preferences and goals and address the resident's nursing medical, physical, mental and psychosocial needs identified in the comprehensive assessment. -The comprehensive care plan will be developed within seven days after the completion of the comprehensive assessment. -The comprehensive care plan will be reviewed and revised, based on changing goals, preferences and needs of the resident, and in response to current interventions. 1. Review of Resident # 162 Annual Minimum Data Set (MDS: a federally mandated assessment tool completed by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADL's) received the necessary services to maintain good personal hygiene when staff did not provide complete perineal care which affected three of the 17 sampled residents, (Residents #9, # 35 and #57), as well as failed to ensure showers were completed for four Residents #2, #45, #50 and #162, and additionally the staff failed to reposition Resident #57 who was dependent upon staff for assistance with repositioning. The facility census was 66. Review of the facility's undated policy for shower/tub bath, showed, in part: - The purpose is to promote cleanliness and comfort, relax the resident, stimulate circulation, and facilitate observation of the resident's skin condition. . Review of the facility's policy for perineal care, dated April 2006, showed, in part: - The purpose was to cleanse the perineum (the thin layer of skin between the genitals 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 observations, interviews and record review, the facility staff failed to assure staff used proper techniques to reduce the possibility of accidents and injuries during the use of a gait belt transfer (a safety device and mobility aid used to provide assistance during transfers, ambulation or repositioning) for one of 17 sampled residents, (Resident #9) and properly transfer two residents (Residents #21 and #4 ) in a manner to prevent accidents. The facility census was 66. Review of the facility provided policy, Accidents, dated 1/30/24 showed: -The facility must ensure that each resident receives adequate supervision and use of assistance devices to prevent accidents. -All staff will commit to and promote safety. Review of the facility policy, Safe Resident Handling/Transfers, dated 2021 showed: -It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote safe, secure and comfortable experience 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 observations, interviews and record review, the facility failed to ensure staff maintained the hydration status for three of the 17 sampled residents, (Resident #2, #8 and #56), and all residents who attended the group meeting, when staff did not pass fresh ice water to the residents. The facility census was 66. Review of the facility's policy for assisted nutrition and hydration, dated 1/30/24 showed, in part: - The purpose is to ensure each resident maintains, to the extent possible, acceptable parameters of nutritional and hydration status and the facility provides nutritional and hydration care and services to each resident, consistent with the resident's comprehensive assessment; - Based on a resident's comprehensive assessment, the facility must ensure that each resident is offered sufficient fluid intake to maintain proper hydration and health. 1. Review of Resident #2's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/3/24 showed:…

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 assure staff provided proper respiratory care for residents, when staff failed to ensure the oxygen concentrator had humidified sterile water which affected two of 17 sampled residents, (Resident #7 and #56), failed to properly clean the oxygen concentrator filter for Resident #56, and additionally failed to date oxygen/ nebulizer tubing for Resident #7 and #56. The facility census was 66. The facility did not provide a policy for respiratory care. 1. Review of Resident #7's Annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/1/24 showed: - Cognitive skills moderately impaired; - Upper extremities impaired on both sides; - Dependent on staff for personal hygiene, - Diagnoses included traumatic brain injury (TBI, happens when a sudden, external, physical assault damages the brain), chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal…

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 staff failed to assess residents for risk of entrapment from bed rails prior to installation and failed to ensure the bed's dimensions were appropriate for the residents size and weight, failed to complete side rail assessments, and failed to obtain a physician's order prior to installation for five of seventeen sampled residents (Resident #45, #216, #14, #1, and #162). The facility census was 66. Facility did not provide a policy on side rails. Review of facility policy, Bed and Bed Rail Maintenance to Reduce/Prevent Entrapment, dated [DATE], showed: -Ensure that facility beds meet FDA guidance to reduce/prevent resident entrapment. The facility will only utilize beds and bed rails that meet this guidance. -Facility will assess the bed and bed rails for each resident and document such assessment prior to the use of bed rails for every resident. If resident uses a different bed or when bed rails are added, the assessment and subsequent…

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, record review, the facility failed to provide sufficient nursing staff to meet the resident needs for six of the 17 residents. When staff failed to timely answer resident call lights, failed to provide assistance for one resident to use the bathroom (Resident #21 ), failed to reposition one resident (Resident #57), failed to provide feeding assistance to one resident (Resident #216), failed to have nursing staff available to speak with family (Resident #216), and failed to provide showers twice a week for three residents (Resident #50, #39, #45) of the 17 sampled residents. The facility census was 66. The facility did not provide a policy regarding staffing. Review of facility policy, resident rights, dated 1/3/24, showed: -The facility will treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance and enhancement of his/her quality of life and recognizes each resident's individuality. -Resident has 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 observations, interviews, and record review, the facility failed to ensure staff administered medications with a medication rate of less than 5% when facility staff made six medication errors out of 25 opportunities and a medication error rate of 24%, . This affected six of the 17 sampled residents, (Resident #6, #34, #39, #47, #51 and #56). The facility census was 66. Review of the facility's undated policy for medication administration, showed, in part: - Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection; - Administer medications as ordered and in accordance with manufacturer specifications. Review of the facility's policy for instillation of eye medication, dated March, 2015, showed: - The purpose is to introduce medication into the eye for treatment or for examination purposes; - Wipe away any…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents were free of significant medication errors when staff failed to prime insulin pens for two residents resulting in three significant medication errors out of the 25 sampled medications. The facility census was 66. Review of the facility's undated policy for medication administration, showed: - Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection; - Administer medications as ordered in accordance with manufacturer specifications. Review of Novo Nordisk (manufacturer of Flex Pen) December 2022 fact sheet showed: -Before each injection, prime your pen by performing an airshot. Turn the dose selector to select 2 units. Holding your pen with the needle pointing up, tap the cartridge gently with your finger a few times to make any air…

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 staffing was sufficient to serve residents their meals in a timely manner. This affected three of the 17 sampled residents (Resident #216, #16, and #8). The facility census was 66. Review of facility policy, assistance with meals, dated March 2016, showed: -Residents will receive assistance with meals in a manner that meets the individual needs of each resident. -Nursing staff and or feeding assistants will serve resident trays and will help residents who require assistance with eating. -Nursing staff will remove food trays from food cart and deliver the trays to each resident's room. -Nursing staff and/or feeding assistants will feed those residents needing full assistance. -Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity. 1. Review of Resident #216's face sheet showed: -Resident admitted to facility on 4/22/24 -Diagnoses included: neurocognitive disorder with lewy bodies (a type of…

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

Based on interviews and record review, the facility failed to have a Quality Assurance and performance Improvement (QAPI) plan and failed to have a plan that contained all required elements. This affected all the residents in the facility. The facility census was 66. The facility did not provide a policy for QAPI. During an interview on 5/9/24 at 9:06 A.M., the Administrator said: - She started as the Administrator on 3/14/24; - At this time she was unable to locate any policies and procedures for QAPI; - They have only had one QAPI meeting. Members who attended were all the department heads, the staffing coordinator and the dietary/housekeeping supervisor; - She talked to the Medical Director monthly.

Based on interviews and record review, the facility failed to ensure they developed and implemented appropriate plans of action to correct identified quality deficiencies as part of their Quality Assessment and Assurance (QAA) committee. This affected all the residents in the facility. The facility census was 66. The facility did not provide a policy in regards to their QAA process or committee. The facility was unable to provide record of the the QAA and Quality Assurance/Performance Improvement (QAPI) plan. During an interview on 5/9/24 at 9:06 A.M., the Administrator said: - She started as the Administrator on 3/1424; - She was unable to locate the policy and procedures for QAPI; - They have only had one QAPI meeting. Members who attended were all the department heads plus the staffing coordinator and the dietary/housekeeping supervisor. She talks to the Medical Director monthly.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to have an Infection Prevention program to include policies and procedures for infection control. Additionally, the facility staff failed to follow acceptable infection control practices to prevent the spread of infection for three residents (Resident #34, #9 and #35) when staff failed to ensure administered medications did not come in contact with unclean surfaces for one resident (Resident #34), failed to wash hands between areas of clean and dirty when providing personal care, failed to clean up bodily fluids from the floor before walking through it and laying a mat over it, for one resident (Resident #9) and touched medications with bare hands for two residents (Resident #34 and #35). The facility census was 66. The facility did not provide a policy on infection prevention and control. 1. During an interview on 05/08/24 at 2:03 PM the Administrator said: -The facility does not have anyone responsible for infection prevention program at…

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 interview, the facility failed to establish an infection prevention and control program (IPCP) that included an antibiotic stewardship program that addressed antibiotic use protocols and a system to monitor antibiotic use. The facility census was 66. The facility did not provided a policy regarding infection control and prevention. Review of Resident #50 Quarterly Minimum Data Set (MDS:a federally mandated assessment tool completed by facility staff) dated 3/1/24 showed: -Brief Interview of Mental Status (BIMS) of 15, indicated no cognitive deficit. -Dependent for Activities of Daily Living (ADL's: tasks performed in a day to care for oneself) Occasionally Incontinent of bowel and bladder. -Diagnoses of cerebral infarction (loss of blood flow to part of the brain: a stroke), cardiovascular disease (heart disease), muscle spasms. cystitis (urinary tract infection). Review of the resident's comprehensive Care Plan dated 3/13/24 showed: -Report any signs and symptoms of urinary tract infection (urgency, burning, pain, nausea, chills, fever, low back pain, foul odor, blood 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 record review and interview, the facility failed to ensure they maintained documentation to show they provided training to their staff regarding what constitute abuse, neglect, exploitation and misappropriation of resident property, procedures for reporting incidents of abuse, neglect, exploitation, or misappropriation of resident property and dementia management and resident abuse prevention. The facility census was 66. The facility did not provide documentation to show they provided training to all staff on abuse, neglect, exploitation and misappropriation of resident property when requested. During an interview on 5/8/24 at 5:31 A.M., Nurse Aide (NA) A said: -He/She had worked at facility a couple of months; -He/She had not had any abuse and neglect training at the facility; -His/Her training involved staff showing him around to every resident, showing him/her supplies, learning what he/she needed to fill out, and telling him/her what he/she could and could not do. During an interview on 5/9/24 at 2:25 P.M., Certified Medication Technician (CMT) B said he/she had not had…

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

Based on interview and record review, the facility failed to ensure the nurse aides (NA) had a minimum of 12 hours of in-service education (which included abuse, neglect, and dementia care) per year by not providing documentation of these in-services for three of three randomly selected nurse aides. The facility census was 66. Review of facility policy, Abuse Prevention Program, dated 1/30/24, showed: -Mandated staff training/orientation programs that include such topics as abuse prevention, identification, and reporting of abuse, stress management, dealing with violent behavior, or catastrophic reactions, and dementia management. Facility did not provide documentation of abuse and neglect or dementia education. During an interview on 5/8/24 at 5:31 A.M., NA A said: -He/She had not had any abuse and neglect training; -He/She had not received any dementia care training. During an interview on 05/09/24 at 1:29 P.M., NA C said: -He/She has not had any training on Abuse and Neglect at this facility; -He/She had training on dementia care. During an interview on 5/15/24 at 2:31 P.M., NA E…

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 closed record review, the facility staff failed to complete a comprehensive discharge summary for one resident (Resident #61) out of three discharged residents. The facility census was 66. The facility did not provide a policy regarding the discharge process. Review of Resident #61 Electronic Medical Record showed: -The resident was admitted to the facility 09/30/2023. - Diagnoses included: Diverticulosis of intestine (small bulging pouches in the digestive tract), Type 2 diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), Mild neurocognitive disorder with behavioral disturbance (a decline in function, memory, learning and attention), dementia with psychotic disturbance (a decline in thinking and problem solving skills as well as seeing/hearing things that are not there or belief that something is real when it is not), Alcohol dependence, Acute metabolic acidosis (a condition in which acids build up in your body.), Hallucinations (seeing or hearing something that isn't there). -The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one resident diagnosed with dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) had a personalized plan of care in place to ensure appropriate services to promote the resident's highest level of functioning and psychosocial needs were provided for one resident (Residents #216) out of the seventeen sampled residents. The facility census was 66. The facility did not provide a policy in regards to addressing behaviors or care for residents with dementia. 1. Review of Resident #216's face sheet, dated 5/7/24, showed: -Resident admitted to facility on 4/22/24 -Diagnoses included: neurocognitive disorder with lewy bodies (a type of progressive dementia that leads to decline in thinking, reasoning, and independent function). Review of Resident's Brief Interview Mental Status (BIMS) Assessment, dated 4/26/24, showed: -Resident had severely impaired cognition.…

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 reconciled Schedule II controlled substances (medications with a potential for abuse and dependence) that were stored in the facility's medication cart and the facility's stat safe (emergency drug supply). This effected Resident #1 and Resident #2. The facility census was 59. Review of the facility's Medication Administration policy, dated 2021, showed: -Medications are to be administered in accordance with professional standards of practice; -If a medication is a controlled substance, the narcotic book must be signed; -Correct any discrepancies and report to the nurse manager. Review of the facility's Controlled Substance Administration and Accountability policy, dated 2023, showed: -The facility will have safeguards in place in order to prevent loss and diversion of controlled substances; -All controlled substances will be accounted for each shift; -The charge nurse or designee will conduct a daily visual audit of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facilty failed to ensure one cognitively impaired resident (Resident #1) was free from sexual abuse by another cognitively impaired resident (Resident #2) when Resident #1 was found in Resident #2's room with the door closed. The door was opened by staff who observed Resident #2 with his/her hand under Resident #1's shirt while resident #2 had his/her pants to his/her ankles, sitting on the side of the bed and fondling his/her genitals. This deficient practice affected one of five sampled resident. The facility census was 59. Review of the facilities undated abuse and neglect policy showed: - Defines sexual abuse as non-consensual sexual contact of any type with a resident. Review of the undated resident rights policy showed each resident has the right to be free from abuse. 1. Review of Resident #1's record showed: - He/She was admitted to the facility on [DATE]; - Diagnoses included: Dementia (a condition characterized by a progressive loss of intellectual functioning…

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 call lights were within the reach of residents and accessible for use within the residents room for two residents (Resident #24 and #28). The facility also failed to provide all residents with home-like dinnerware during meal service, and failed to give Resident #31 a wheelchair that properly fits him/her, in a timely manner. The facility census was 47. The facility did not provide a policy regarding call light accessibility. The facility does not have a policy pertaining to proper dinnerware. 1. Observation and interviews of the Dining Room on 9/12/22 at 12:10 P.M. showed: -The salad was served out of a styrofoam bowl and dessert was on a paper plate. The salad fork was plastic. -Numerous residents within the dining room and in their rooms said that they have been served on plastic plates and in styrofoam containers. They do not know why and wondered if the facility did not have enough dishes to serve food on. During an interview…

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 clarify the status of the advanced directives of two residents (Residents #6 and #35) of 12 sampled residents. The facility census was 47. The facility did not provide a policy on advanced directives. 1. Review of resident #6's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff dated [DATE] showed: -admitted to facility on [DATE] with a Brief Interview for Mental Status (BIMS) of an 8 out of a possible 15. A score of 8 indicates resident is considered to be mildly impaired. -Review of the Annual MDS dated [DATE] resident has a BIMS of 6 equals very severe impairment. Review of resident #6's medical record on [DATE] at 2:18 P.M. showed: - An incapacitation letter (A letter of incompetency is a statement from a physician certifying that a person is incapable of making informed decisions about their health care, finances, and estate.) and Durable Power Of Attorney (DPOA) were on file. -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 care plan with the resident's specific conditions, needs, and risks to provide effective person centered care for two residents ( Resident #23 and Resident #24) out of the 12 sampled residents. The facility census was 47. Facility's care plan comprehensive policy provided from their nursing guideline manual states: - Purpose: An individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental, and psychosocial well -being. - Guidelines: The interdisciplinary care plan team with input from the resident, family, and or legal representative, will develop and maintain a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. The comprehensive care plan will be based on a thorough assessment that includes, but is not limited to the MDS (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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities designed to meet the resident's interests for seven residents (Resident #6 #39, #38, #23, #31, #35 and #24) out of 12 sampled residents. The facility census was 47. Review of Resident Activities Policy on 9/15/22 at 1:52 P.M. showed: -An activity program is planned for each resident as part of their total resident care by the Activity Director, in cooperation with Nursing and with Physician approval. Residents shall be encouraged, but not forced, to participate in activities of choice. -An individualized program will be implemented for residents unable to participate in or attend. 1. Review of Resident #6's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by staff, dated 9/12/22 showed: -Brief Interview for Mental Status (BIMS It is a screen used to assist with identifying a resident's current cognition ) was a 10 out of 15 which showed moderately impaired…

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 prepare and serve foods that were attractive and palatable to residents. The facility census was 47. Review of Test Meals policy dated April 2011 states: The test meals will be tested at point of delivery to residents. 1. The meal tested should vary (All meals should be examined.). 2. The destination of the tray will also vary. 3. The diets that are tested will be regular and pureed. 4. The test tray will be the last tray on the cart and is tested after all other trays have been served. 5. The Dining Services Manager is responsible for these guidelines. 6. Hot foods should be delivered to the resident at least 120 degrees Fahrenheit (F). 7. Cold foods should be delivered to the resident at 40 degrees F or below. Review for Refrigerator and Freezer Temperatures policy dated April 2011 states: 1. Temperature of refrigerators should be 33-40 degrees F. 2. There should be a thermometer in all refrigerators and freezers. Thermometers should be located in front of the unit. 3. Temperatures should be checked…

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 issue a written discharge notice to two residents (Residents #39 and #38). The facility census was 46. The facility did not provide a policy regarding discharge notices. 1. Review of Resident #39's admission Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 7/29/22, showed: -The resident is able to make self understood and understand others. -The resident scored 15 on the Brief Interview for Mental Status (BIMS), a structured evaluation aimed at evaluating aspects of cognition in elderly patients. This indicates the resident is cognitively intact. -The resident has the diagnoses of anemia (a condition in which a person lacks enough healthy red blood cells to carry adequate oxygen to the body's tissues), heart failure, anxiety, depression, respiratory failure and swallowing difficulty with a feeding tube (a medical device used to provide nutrition to people who cannot obtain nutrition by mouth or are unable to swallow…

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 inform resident's and their family/legal representatives of the bed hold policy at the time of transfer/discharge to the hospital for two residents. (Residents #39 and #38). The facility census was 46. Review of the facility Bed Hold Policy showed: -The facility will notify all residents and/or their representative of the bed hold guidelines. This notification shall be given 1. upon admission the the facility, 2. at the time of transfer to the hospital or leave, and 3. at the time of non-covered therapeutic leave. 1. Review of Resident #39's admission Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 7/29/22, showed: -The resident is able to make self understood and understand others. -The resident scored 15 on the Brief Interview for Mental Status (BIMS), a structured evaluation aimed at evaluating aspects of cognition in elderly patients. This indicates the resident is cognitively intact. -The resident has the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents who were unable to carry out their own activities of daily living (ADLs) received the necessary services to maintain good personal hygiene for two residents (Resident #23 and #24) out of 12 sampled residents. The facility census was 46. Review of the facility's undated Activities of Daily Living policy, showed: -It is the policy of this facility to specify the responsibility to create and sustain an environment that humanizes and individualizes each resident's quality of life by ensuring all staff, across all shifts and departments, understand the principles of the quality of life, and honor and support these principles for each resident; and that the care and services provided are person centered and honor and support each resident's preferences, choices, values, and beliefs. -A resident who is unable to carry out activities of daily living will receive the necessary services needed to maintain good nutrition, grooming,…

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 the necessary care and services to attain or maintain the highest practicable physical, mental, or psychosocial well-being for one residents (Resident #92) when the facility failed to conduct skin assessments and a wound care treatment for Resident #92 upon admission. The facility census was 46. The facility did not provide a policy on skin assessment. The facility did not provide a policy on wound care. 1. Resident #92 was admitted to the facility on [DATE] with the diagnoses of deep vein thrombosis (a medical condition that occurs when a blood clot forms in a deep vein), lymphedema (refers to tissue swelling caused by an accumulation of protein-rich fluid that's usually drained through the body's lymphatic system), epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received appropriate treatment and services to maintain or improve mobility when staff did not provide range of motion for two residents or a restorative program for contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) prevention and treatment (Resident #23 and #24). The facility census was 46. Review of the facility Restorative Program policy, dated May 2006, showed: -It is the purpose of this policy to see that each resident receives and the facility provides the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and care plan. -It is the entire staff's responsibility to prevent deterioration and further functional loss of each resident in the facility. The objective is to provide restorative care necessary to meet…

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 dietary staff served hot foods hot when they did not take temperatures of pureed foods prior to meal service and did not follow their policy to serve food at least 120 degrees Fahrenheit. The facility census was 47. Review of the undated facility policy for Food storage showed 1. Proper labeling and dating of all foods. All foods will be considered as leftovers unless in the original container with an expiration date. Leftovers will be discarded after third (3rd) storage day. 2. All food will be stored in appropriate containers. 3. Resident foods will be stored in a designated specific storage area, unless resident has a personal refrigerator in their room. 4. Resident food storage areas will be identified. Monitoring Temperatures: 1. Refrigerator temperatures will be monitored on a routine and consistent basis. 2. Thermometers will be intact and maintained. Test Meals: The test meals will be tested at point of delivery to residents. 1. The meal tested should vary (All meals should be examined.). 2. 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.