Aspire Senior Living Poplar Bluff

Based on observation, interview, and record review, the facility failed to maintain an error rate of less than five percent (%) when medications were administered. There were 34 opportunities with six errors made, for an error rate of 17.6% which affected three residents (Residents #12, #29, and #32) out of four sampled residents. The facility census was 50.The facility did not provide a policy for insulin administration. Review of the Humalog/insulin lispro (a rapid-acting insulin) and NovoLog/ insulin aspart (a rapid-acting insulin) Pen's Manufacturer Guidelines for Priming Before Each Injection and Administration, revised 02/2023, showed:- Turn the dose selector to select two units;- Hold the pen with the needle pointing up;- Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge;- Keep the needle pointing upwards, press the push-button all the way in;- The dose selector returns to zero;- A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than six times. 1. Review…

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 drugs and biologicals were labeled in accordance with currently accepted practices, failed to store medications in a safe and effective manner when staff left the medication refrigerator narcotic medication behind only one lock, and failed to check and maintain a daily refrigerator temperature log. This had the potential to affect all residents. The facility census was 50. Review of the facility policy titled, Labeling of Medications and Biologicals, dated 10/01/25, showed:- Medication labels must be legible at all times;- Any medication label that is soiled, incomplete, illegible, worn, or makeshift must be returned and replaced by the issuing pharmacy, not merely covered;- Labels for multi-use vials must include the date the vial was initially opened or accessed (needle-punctured), all opened or accessed vials should be discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial, and unopened or unaccessed vials should be discarded according 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.

Based on record review and interview the facility failed to provide prescription medications as ordered and notify the physician of the medications not available for administration, in accordance with standards of practice, for one resident (Resident #1) of three sampled residents. The facility census was 50.Review of the facilities undated policy regarding unavailable medications directs staff to:-Maintain a contract with a pharmacy provider to supply the facility with routine, as needed (prn) and emergency medications;- Determine reason for unavailability, length of time medication is unavailable, and what efforts have been attempted by the facility or pharmacy provider to obtain the medication;- Notify physician of inability to obtain medication, upon notification or awareness that the medication is not available. Obtain alternative treatment order and or/ or specific orders for monitoring resident while medication is on hold;- If a resident misses a scheduled dose of medication, staff shall follow procedures for medication errors, including physician/family notifications,…

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 physician's orders for one resident (Resident #1) out of five sampled residents by not administering the resident his/her medications in a timely manner. The facility census was 55. The administration was notified on 09/09/25 of the Past Non-Compliance which occurred on 08/17/25. On 08/31/25, upon notification, the facility administration started an investigation and completed a medication error report. In-serviced staff on Medication Administration Compliance. The non-compliance was corrected on 09/02/25, as the facility in-serviced the nursing staff responsible for medication administration on the facility's policy and procedures for Medication Administration Compliance. The facility policy titled, Physician/Practitioner Orders, undated, showed:- For all physician/practitioner orders received via telephone, the nurse will:a. Document the order notating the time, date, name and title of the person providing the order, and the…

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

Based on observation, interview, and record review, the facility failed to assess the use of a merry walker (an enclosed framed wheeled walker with a seat) to determine if it was a restraint, and failed to document an ongoing re-evaluation for the use of the merry walker for one resident (Resident #12) out of one sampled resident with a restraint. The facility census was 47. Review of the facility's policy titled, Use of Restraints, undated, showed: - Purpose is to ensure that physical and/or chemical restraints are used only when needed to treat the resident's medical symptoms and then, only use the least restrictive alternative for the least amount of time; - The resident's record includes ongoing re-evaluation for the need for a restraint and is effective in treating the medical symptom; - The resident's comprehensive care plan will reflect the resident's goals and the interventions/services needed for the safe use of a restraint as long as it is medically necessary. The facility did not provide a policy regarding merry walkers. 1 Review of Resident #12's April 2024 Physician's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide scheduled showers for three residents (Residents #5, #24 and #32) out of four sampled residents for activities of daily living (ADLs). The facility census was 47. Review of the facility's policy titled, Necessary Care and Services, dated 01/20/24, showed: - The facility will ensure that a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, personal and oral hygiene. 1. Review of Resident #5's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by the facility), dated 10/08/24, showed: - Dependent for personal hygiene and showers. Review of the resident's care plan, revised 10/13/24, showed: - Did not address showers/bathing frequency; - Did not address assistance required for showers/bathing. Review of the shower schedule, dated 12/01/24 - 01/07/25, showed the resident's showers were scheduled for Monday and Thursday night…

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 utilized safe transfer techniques for one resident (Resident #29) when staff failed to transfer the resident with assist of a gait belt (a device used to aid in the safe movement of a person from one place to another) of one sampled resident. The facility census was 47. Review of the facility's policy titled, Policy on the Use of Gait Belts in Long-Term Care Facilities, dated 01/30/24, showed: - Purpose is to ensure the safe and effective use of gait belts in assisting residents with mobility and transfers, thereby reducing the risk of injury to both residents and staff in long-term care facilities; - Gait belts must be used when assisting residents who require help with walking, standing, or transferring; - Gait belts should be used for residents with unsteady gait, those at risk of falls, or those who need support during mobility activities; - Residents who refuse the use of a gait belt must be accommodated with alternative methods of assistance. 1. Review of Resident #29's medical record showed: - An…

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

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #12) out of five sampled residents who were incontinent of bowel and bladder, received appropriate treatment and services after an incontinent episode. Resident #12 was left without personal care for over six hours, resulting in the resident's brief soaked with dark urine and a strong urine odor. The census was 47. Review of the facility's policy titled, Necessary Care and Services, dated, 01/20/24, showed: - The facility will ensure that a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain good nutrition, grooming, personal and oral hygiene. 1. Review of Resident #12's quarterly Minimum Data Sets (MDS - a federally mandated assessment instrument completed by the facility staff), dated 07/26/24 and 10/25/24, showed: - Severe cognitive impairment; - Impairment on both sides of the upper and lower extremities; - Dependent, full assist for sit to stand and transfers; - Totally dependent for personal hygiene; - Totally…

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 standards of practice when licensed staff didn't assess one resident's (Resident #12) gastrostomy tube (G-tube) (a small tube that's surgically inserted into the stomach through the abdomen) out of one sampled resident upon readmission to the facility from the emergency room (ER) when the G-tube was replaced after the resident pulled it out at the facility. This resulted in the facility holding the resident's feedings without a physician order for 11 days. The facility also failed to follow physician orders in obtaining weekly weights. The facility census was 47. Review of the facility's policy titled, Enteral Nutrition, dated 01/20/24, showed: - Responsibility of licensed nurse; - Assessment guidelines include; condition of mouth and gums, consistency of feces, condition of skin around feeding tube, weight, nutritional status, hydration, ability to chew and swallow, obstruction of esophagus; - Documentation guidelines: reason…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide documentation of on-going assessments and monitoring after dialysis (a process for removing waste and excess water from the blood) center for one resident (Resident #36) out of one sampled resident. The facility's census was 47. Review of the facility's policy, Dialysis, undated showed: - This facility will ensure that residents who require dialysis receive such services consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences; - The facility will ensure appropriate monitoring of the dialysis resident's status before, during, and after the treatments; - If this facility does not employ a qualified professional person to furnish dialysis treatments, the facility will enter into an agreement with a person or agency outside of the facility. This agreement constructs a connection between both entities and fosters accountability that is vital to the health of 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.

Based on interview and record review, the facility failed to limit the use of an as needed (PRN) order for psychotropic (medications that affect how the brain works and causes changes in mood, awareness, thoughts, feelings, or behaviors) medications to 14 days for three residents (Residents #17 and #30) out of two sampled residents and Resident #9 outside of the sample. The facility census was 47. The facility failed to provide a policy for the 14 day stop date on PRN psychotropic medications. 1. Review of Resident #9's January 2025 Physician's Order Sheet (POS) showed: - Diagnosis of restlessness, agitation, and insomnia (difficulty sleeping); - An order for lorazepam (an anti-anxiety medication) 2 milligram (mg)/ milliliter (ml) 0.5 ml sublingually (under the tongue) every two hours PRN for restlessness, dated 11/18/24; - An order for lorazepam 0.5 mg tablet by mouth every four hours PRN for anxiety (persistent worry and fear about everyday situations), dated 11/27/24; - The facility did not provide a 14 day stop date order for the PRN lorazepam order. Review of the resident's…

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

Based on observation, interview, and record review, the facility failed to label and store medications in a safe and effective manner when opened insulin was found undated in the medication cart and failed to ensure the medication cart was locked while unattended. This had the potential to affect all residents. The facility census was 47. Review of the facility policy titled, Storage of Medication, dated 01/20/24, showed: - Compartments containing medications are locked when not in use and should not be left unattended; - Narcotics should be double locked at all times. The facility failed to provide a policy regarding dating insulin pens. Review of the manufacturer's recommendations for Lantus (a long-acting type of insulin), dated June 2023, showed: - Discard the medication 28 days after opening. Review of the manufacturer's recommendations for lispro insulin pen (a fast acting type of insulin), dated 2023, showed: - Discard the medication 28 days after opening. Review of the manufacturer's recommendations for Admelog insulin pen (a fast acting type of insulin), dated August 2023,…

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 update the facility assessment (an assessment to determine what resources were necessary to care for residents competently during both day-to-day operations and emergencies) at least annually. The facility census was 47. Review of the facility's policy titled, The Purpose and Importance of a Facility Assessment, dated 08/07/24, showed: - Resident profile - the number of current residents and which of their needs have been identified, including physical, medical, ethic, cultural, or religious needs; - Care provided - what care and services are currently provided or offered to residents at the facility; - Resources needed - based on the needs identified in the resident profile, what the facility's staffing, equipment, and supplies are needed to properly care for the residents; - The assessment must be conducted, at a minimum, annually and updated as necessary. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to 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 maintain proper infection control practices during the hall tray meal pass, during incontinent care for two residents (Residents #24 and #40) out of four sampled residents, and during the medication pass for two residents (Residents #24 and #44) out of two sampled residents. The facility also failed to correctly screen five residents (Residents #4, #12, #20, #28, and #97) for tuberculosis (TB - an infectious disease characterized by the growth of nodules in the tissues, especially the lungs) out of five sampled residents required by state regulation 19 CSR 20-20.100. The facility census was 47. Review of the facility's policy titled, Hand Hygiene, dated 01/20/24, showed: - Handwashing will be regarded by this facility as the single most important means preventing the spread of infection; - Staff will follow the facility's established hand hygiene procedures to prevent the spread of infections and diseases to other staff, residents, and…

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

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This has the potential to affect all residents. The facility census was 42. The facility failed to provide a policy. 1. Observation on 11/28/23 at 9:29 A.M., of the kitchen showed: - Scrap food items floated in the clogged garbage disposal sink; - The commercial range with brown grime build-up around the control knobs; - Food debris, oily film build-up, two drinking cups, one egg roll on the floor beneath the range; - Microwave oven interior with splattered food debris on all surfaces; - Storage below microwave with splattered grease and food debris on metal bowls and shelf surface; - Storage below steam table with four- twenty quart (qt.) pots with a brown substance on interior surfaces; - Spray bottle with bleach cleaner sat on the window shelf above sink with black grime and scattered debris; - Cabinet drawers contained cooking utensils and scattered debris on the bottom surface; - 1 inch…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a facility-initiated transfer when two residents (Resident #17 and #41) out of 14 sampled residents transferred to the hospital. The facility's census was 42. Review of the facility's policy titled Discharge/Transfer of Resident, undated showed: - Purpose is to provide safe departure from the facility and to provide sufficient information for aftercare of the resident; - Notice of transfer or discharge to be provided as necessary; - Bed hold forms to be provided as necessary. 1. Review of Resident #17's medical record showed: - Resident transferred to the hospital for medical evaluation on 09/07/23 and readmitted to the facility on [DATE]; - No documentation of written notification to the resident and/or the resident's representative of the resident's transfer to the hospital on [DATE]. 2. Review of Resident # 41's medical record showed: - Resident transferred to the hospital for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide written notification of their bed-hold policy to residents and/or their representatives at the time of transfer for two residents (Resident #17 and #41) out of 14 sampled residents. The facility's census was 42. Review of the facility's Bed Hold Guidelines policy, undated, showed: - This facility will notify all residents and/or their representatives of the bed hold guidelines. This notification shall be given on admission to the facility, at the time of transfer to the hospital and at the time of non-covered therapeutic leave. Review of the facility's policy titled Discharge/Transfer of Resident, undated showed: - Purpose is to provide safe departure from the facility and to provide sufficient information for aftercare of the resident; - Notice of transfer or discharge to be provided as necessary; - Bed hold forms to be provided as necessary. 1. Review of Resident #17's medical record showed: - Transferred and admitted to the hospital on…

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

Based on interview and record review, the facility failed to implement a baseline care plan (the minimum healthcare information necessary to properly care for a resident) upon admission with specific interventions for two residents (Resident #12 and #144) out of two sampled residents. The facility census was 42. Review of the facility's policy titled, Care Plan - Preliminary, dated December 2016, showed: - To assure the resident's immediate care needs are met and maintained, a hand written temporary care plan will implemented for the resident following the admission assessments and interviews with the resident, this handwritten care plan will be started by the admission nurse and updated by nurses of each shift for the first 24 hours; - The Interdisciplinary care plan team (members from different disciplines working together for a common purpose) and/or admitting nurse will review the physician orders and implement a nursing care plan to meet the immediate care needs of the resident; - The temporary care plan will be used until the comprehensive assessment has been completed and an…

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

Based on observation, interview and record review, the facility failed to implement a care plan with specific interventions to meet individual needs for two residents (Resident #20 and #31) out of 14 sampled residents. The facility census was 42. Review of the facility's policy titled, Care Plan Temporary, dated March 2015, showed: - The temporary/handwritten care plan will include, but not limited to quality of care problems, quality of life problems, diagnosis, medications and treatments ordered; - The care plans will include problems, goals, time frames, and interventions related to the immediate care needs. 1. Review of Resident #20's medical record showed: - An admission date of 11/16/22; - Diagnoses of chronic obstructive pulmonary disease (COPD, a lung disease that blocks airflow and makes it difficult to breathe) and generalized muscle weakness; - No documentation of the evaluation for bed rails; - No documentation of signed consent by the resident or the resident's representative for bed rails; - Fall risk assessment, dated 11/09/23, showed the resident as a moderate fall…

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 assess residents for the use of bed rails prior to installation or use nor did they obtain informed consent from the resident or if applicable, the resident representative for two residents (Resident #11 and #20) out of 14 sampled residents and one resident (Resident #2) outside the sample with bed rails in use. The facility's census was 42. Review of the facility's policy titled, Restraints, Physical, dated March 2015, showed the following: - If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the attending physician, and input from the resident and/or legal representative; - The staff shall obtain consent for the use of side rails from the resident or the resident's legal representative prior to their use; - Side rails may be used if assessment and consultation with the attending physician has determined that they are needed to help manage a medical symptom or condition, or to help…

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 #32 and #36) outside of the sample were free of significant medication errors when staff failed to prime an insulin (medication used to lower blood sugar) pen and hold for a count of six seconds at the site of administration as recommended by the manufacturer to ensure the residents received the full and correct dose of insulin. The facility's census was 42. Review of the facility's policy titled, Medication, Administration Guidelines, dated March 2015, showed: - It is the purpose of the facility that residents receive their medications on a timely basis and in accordance with established policies; - The complete act of administration entails removing an individual dose from a previously dispensed, properly labeled container, verifying it with the physicians' orders, giving the individual dose to the proper resident and promptly recording the information. Review of the Novolog (insulin) Kwik Pen manufacturer instruction manual showed: - The pen must be primed before use; - 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.

Based on observation and interview, the facility failed to ensure the dumpster was maintained to keep pests out and/or to keep the garbage contained in the dumpster. This failure had the potential to affect all residents. The facility census was 42. Review of the facility's Waste Disposal policy, dated April, 2011, showed: - Dumpster lids are to be closed at all times; - Dumpster and dumpster area are to be kept clean and free of debris. 1. Observation on 11/28/23 at 9:49 A.M., and 12:52 P.M., 11/29/23 at 3:06 P.M., 11/30/23 at 4:05 P.M., and 12/01/23 at 8:00 A.M., and 10:32 A.M., of the outside trash dumpster located near the kitchen entrance showed: - One 8 yard (yd.) dumpster partially filled with one plastic lid completely opened; - Twelve soiled disposable exam gloves, scattered debris, 1 broken porcelain toilet lid, and two damaged wheel chairs lay on the ground beside the dumpster; - Oily grime build-up along the front concrete edge of dumpster area. During an interview on 12/01/23 at 11:03 A.M., the Maintenance Director said the trash dumpster should be closed when it was…

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

Based on observation, interview, and record review, the facility failed to maintain adequate infection control practices to prevent the transmission of infection when staff demonstrated poor hand hygiene for two residents (Resident #4, and #33) out of two sampled residents. The facility also failed to ensure the prevention of communicable disease in regards to Tuberculosis (TB) (a communicable disease that affects the lungs characterized by fever, cough and difficulty breathing) by not completing the admission TB screening and/or a yearly risk assessment for symptoms for five residents (Resident #1, #8, #18, #19, and #24) out of five sampled residents. The facility census was 42. Review of the facility's policy titled, Perineal Care, dated March 2015, showed: - To cleanse the perineum; - To prevent infection and odor; - Put on disposable gloves; - Wet washcloth and make a mitt with it. Apply soap lightly; - Use one gloved hand to stabilize and separate the labia, with the other hand, wash from front to back; - Rinse and pat dry; - Use a new washcloth and wash around the anus. Rinse…

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 designate one or more individuals with the required primary professional training as the Infection Preventionist (IP) for the facility's infection prevention control program. The facility census was 42. The facility did not provide a policy regarding required primary professional training for the Infection Preventionist. During an interview on 12/01/23 at 9:30 A.M., the Infection Preventionist said that he/she is not a nurse nor is he/she trained in any other related field. The IP said that he/she is a licensed nursing home administrator and has successfully completed the nursing home infection preventionist training course. The IP said that he/she thought the regulation had changed and that anyone who completes the nursing home infection preventionist training could be the IP. During an interview on 12/01/23 at 10:40 A.M., the Administrator said that she was told that the Infection Preventionist could be anyone who had completed the nursing home infection preventionist training course.

Based on observation, interview, and record review, facility staff failed to conduct regular inspections of all bed frames and rails as part of a regular maintenance program for two resident's (Resident #11 and #20) out of 14 sampled residents with bed rails in use. The facility's census was 42. Review of the facility's policy titled, Restraints, Physical, dated March 2015, showed the following: - Inspect by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; - The maintenance department shall provide a copy of inspections to the administrator and report results to the QA committee for appropriate action. Copies of the inspection results and QA committee recommendations shall be maintained by the administrator and/or safety committee. 1. Observations of Resident #11 showed: - On 11/28/23 at 11:01 A.M., resident in bed with quarter side rail up on left side of bed; - On 11/29/23 at 8:57 A.M., resident in bed with quarter side rail up on left side of bed; - On 11/30/23 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain a safe, clean, comfortable, homelike environment. The deficient practice had the potential to affect all residents and staff in the facility. The facility census was 42. The facility did not provide a policy. 1. Observation on 11/28/23 at 10:38 A.M. of room [ROOM NUMBER], showed: - One, 9 inch (in.) x 11 in. picture frame and two, 5 in. x 7 in. picture frames on top of the light fixture above the bed and one five foot long foil [NAME] draped over the light fixture above the head of the bed by the door. 2. Observation on 11/28/23 at 10:56 A.M., of room [ROOM NUMBER], showed: - One, 8 in x 11 in. canvas painting on top of a light fixture above the bed by the door; - Two, 2 foot areas of dry wall damage at head of bed, one tube of cream on top of a light fixture above bed, and a wooden board covered in plexiglass attached to the wall on the left side of the bed closest to the window had damage along the top edge with pieces of wood…

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 conduct at least twelve hours of nurse aide in-service education per year and failed to provide the required annual competencies of abuse prevention and dementia care for two out of two nurse aides sampled. The facility census was 42. The facility did not provide a policy. 1. Record review of the facility's 2023 in-service records showed: - Certified Nursing Assistant (CNA) C with a hire date of 12/07/20; - CNA C attended a total of one hour of in-services; - CNA C did not attend an annual competency in-service on abuse prevention; - CNA C did not attend an annual competency in-service on dementia care. 2. Record review of the facility's 2023 in-service records showed: - CNA F with a hire date of 09/17/15; - CNA F attended a total of one hour of in-services; - CNA F did not attend an annual competency in-service on abuse prevention; - CNA F did not attend an annual competency in-service on dementia care. During an interview on 11/30/23 at 8:30 A.M., the Infection Preventionist said training is provided during staff…

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.