Edgewood Manor Health Care Center

Based on observation, interview, and record review, the facility failed to ensure medication carts were locked when staff was not in sight of the cart, failed to ensure medication carts were clean and did not contain other non medical objects, failed to ensure the medication refrigerator's temperature was within temperature range by not checking it daily, failed to ensure nursing staff was counting narcotics at the beginning and end of each shift for three sampled residents, (Resident #61, #42, and #325) out of 19 sampled residents. The facility census was 74 residents. Review of the facility's policy, Medication Storage Policy, dated 5/18/24 showed: -All drugs and biologicals would have been stored in locked compartments under proper temperature controls. -During a medication pass, medications must be under the direct observation of the person administering medications or locked. -Any discrepancies which could not been resolved must have been reported immediately as follows: -Notify the Director of Nursing (DON), charge nurse, or designee and the pharmacy. -Complete an incident…

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 keep the walk-in refrigerator, and walk-in freezer floors clean; failed to retain operable thermometers in all refrigerators and/or freezers to confirm adequate temperature ranges; failed to safeguard against foreign material possibly getting into food and/or beverages; failed to keep trash dumpsters lidded; failed to consistently measure and document hot food temperatures at the oven and/or stove, or steam table to ensure they were suitably cooked, and cooked longer if needed, to lessen the chance of bacterial contamination; failed to maintain plastic and/or rubber cutting boards and utensils in good condition to avoid food safety hazards (cross-contamination); failed to separate damaged foodstuffs; failed to store foodstuffs within acceptable temperature parameters; and failed to ensure the proper labeling, refrigeration, and/or disposal of foodstuffs to preserve their freshness, in accordance with State of Missouri rules and regulations, established national guidelines, and professional standards for food service safety.…

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 2. Review of the facility's policy titled Tuberculosis Testing dated 6/29/23 showed new employees would receive a two-step Tuberculin Skin Test (TST-used to screen for TB). Review of the facility's list of employees hired since the facility's last annual survey showed: -Employee A was hired on 7/16/24. -Employee B was hired on 6/25/24. -Employee C was hired on 5/29/24. -Employee D was hired on 8/27/24. -Employee E was hired on 6/25/24. -Employee G was hired on 4/17/24. -Employee H was hired on 8/6/24. -Employee J was hired on 7/2/24. Review of the above employees' employee files showed employees A, B, C, D, E, G, H, and J did not have any TSTs completed. During an interview on 9/24/24 at 3:46 P.M., the Human Resources Director said: -He/She started working at the facility at the end of July 2024. -He/She asked the Director of Nursing (DON) to make sure the employee TSTs were completed. During an interview on 9/25/24 at 1:19 P.M., the Administrator said: -They were supposed to be doing TSTs on new employees when…

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 an Infection Preventionist (IP) for the facility's Infection Prevention control program. The facility census was 74 residents. The certifications were requested for all employees who were certified in the IP program and were not received at the time of exit. 1. Review of the Centers for Disease Control (CDC) online IP course showed: -The Minimum Data Set (a federally mandated assessment tool completed by facility staff for care planning) Coordinator had completed 15 of the 26 modules for the CDC IP course. -He/She worked 15 hours a week as the IP. During an interview on 9/27/24 at 9:32 A.M. the MDS Coordinator said: -He/She had started the IP course a couple of years ago. -He/She had not finished the IP course. -He/She was not certified in the IP program. -He/She worked 15 hours a week as the IP. During an interview on 9/27/24 at 12:00 P.M. the Director of Nursing (DON) said: -He/She had completed the IP program training and had 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 and interview, the facility failed to maintain a safe, clean, comfortable and homelike environment including, but not limited to, unbroken furniture and/or window treatments, clean and comfortable sleeping conditions, and a physical layout of the facility that maximized people with disabilities' independence, met The Americans with Disabilities Act (ADA) requirements, and did not pose a safety risk and/or tripping hazards. These deficient practices had the potential to affect all residents, visitors, volunteers, and staff who resided, visited, used, or worked in at least four locations throughout the building. This facility had a census of 74 residents with a licensed capacity of 91 residents at the time of the survey. 1. Observation on 9/24/24 at 11:48 A.M. during the initial facility walk-through inspection showed the plumbing clean out (the access point for a sewer line and is considered a means to access the sewer line for cleaning and unclogging) in the middle of the 300 Hall 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 interview and record review, the facility failed to notify the resident and/or the resident's representative(s) of a transfer to a hospital, including the reasons for the transfer in writing and failed to provide the Ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) a copy of the notification for three sampled residents (Residents #33, #73, and #40) out of 19 sampled residents. The facility census was 74 residents. Review of the Facility's Resident Transfer/Discharge, Immediate Discharge, and Therapeutic Leave Policy dated 5/14/2024 showed: -Any resident transferred or discharged under a Facility-Initiated Transfer or discharge the Facility must: --Notify the resident and the resident representative the reason for the transfer or discharge in writing in a manner they understand. --Notify a representative of the Office of the State Long-Term Care Ombudsman. ---A copy of the discharge/transfer notice shall be sent to the Ombudsman 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 interview and record review, the facility failed to provide a bed hold notification to a resident or resident representative upon transfer or discharge for three residents (Resident #40, #33, and #14) out of 19 sampled residents. The facility census was 74 residents. Review of the facility's Bed Hold Policy, date 11/6/23, showed: -When a resident was admitted to the facility, they received a copy of the bed hold policy from the admission Packet. -When a resident was discharged to the hospital or went on therapeutic leave, the facility provided a a copy of the Bed Hold Policy to the resident or resident representative. -When a resident was admitted following a hospitalization or therapeutic leave, the resident will be admitted to the facility if they continue to require services from the facility and was eligible for Medicare skilled nursing facility services or Medicaid nursing facility services. 1. Review of Resident #40's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument…

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 accurately assess the resident's dental status for two sampled residents (Resident #33 and #51), and failed to accurately assess and implement strategies for unintended weight gain and loss for one sampled resident (Resident #19) out of 19 sampled residents. The facility census was 74 residents. Review of the facility's policy titled Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) 3.0, Care Assessment Summary and Individualized Care Plans dated 11/6/23 showed: -The purpose of the policy was to ensure the MDS was completed accurately. -The dental health section of the MDS was to be completed by nursing staff. -The dental health section of the MDS was to be used to document any dental problems. -Section K (swallowing/nutrition status): --Was to be completed by the dietary manager. --Used to assess conditions that affected the resident's ability to maintain adequate nutrition 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 develop a comprehensive person-centered care plan for four sampled residents (Residents #33, #54, #20 and #51) out of 19 sampled residents. The facility census was 74 residents. Review of the facility's policy titled Comprehensive Care Plans dated as revised on 6/26/24 showed: -The facility staff would develop and implement a comprehensive, person-centered care plan for each resident to meet the resident's needs. -The care plan would include resident-specific interventions. 1. Review of Resident #33's baseline care plan dated 2/5/21 did not include anything about the resident's teeth. Review of the resident's dental progress note dated 2/13/23 showed: -The resident was interested in dentures. -Four teeth were removed. Review of the resident's dental progress note dated 2/16/23 showed: -Four of his/her teeth were removed. -The fifth tooth was not removed because the resident did not get numb on that tooth. Review of the resident's annual…

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 2. Review of Resident #33's quarterly MDS dated [DATE] showed the resident had not fallen since admission or prior assessment, whichever was more recent. Review of the resident's health status note dated 4/7/24 showed the resident was sent to the hospital emergency department related to his/her altered mental status after a fall. Review of the resident's discharge assessment dated [DATE] showed the resident had two or more non-injury falls since admission or prior assessment, whichever was more recent. Review of the resident's discharge assessment dated [DATE] showed the resident had one non-injury falls since admission or prior assessment, whichever was more recent. Review of the resident's quarterly MDS dated [DATE] showed the resident had one non-injury fall since admission or prior assessment, whichever was more recent. Review of the resident's care plan updated 7/28/24 showed falls and fall-prevention interventions were not included in the care plan. During an interview on 9/25/24 at 9:50 A.M., the MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the required annual 12 hours of in-service training for Certified Nursing Assistants (CNA). The facility census was 74 residents. Review of the facility Nursing Assistant Training Program Policy dated 5/18/24 showed: -Each nursing assistant shall be provided at least 12 hours of in-service training annually, based on his/her employment date, not calendar year. -It is the responsibility of the employee to attend/complete mandatory in-service training's to maintain employment status with the facility. -A review of the employee's attendance/completion records shall be performed at least annually, such as at time of performance review. -Some of the minimum training includes: --Dementia management and care of the cognitively impaired. --Abuse, neglect, and exploitation prevention. --Resident rights and facility responsibilities. --Behavioral health. --Identification of changes in condition. 1. Review of the Facility assessment dated [DATE] 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 observation, interview, and record review, the facility failed to ensure staffing was posted correctly including the total number and actual hours worked for Registered Nurses (RN's), Licensed Practical Nurses (LPN's), Certified Nursing Assistants (CNA's), and Certified Medication Technicians (CMT's) directly responsible for resident care per shift which could have the potential to affect all residents, staff, and visitors of the facility. The facility census was 74 residents. Requested the facility policy for daily posted staffing and did not receive it. 1. Review of the Facility assessment dated [DATE] showed nursing services required daily was: -1 Director of Nursing (DON) full time days. -4 LPN's. -4 CMT's. -10 CNA's. Observation on 9/23/24 at 10:10 A.M., of the glass case bulletin board in the common area near the 600-hall showed: -Staffing sheets for 9/20/24, 9/21/24, 9/22/24 and 9/23/24. -The staffing sheets showed the names of the staff working for each position. -Did not show the number of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a Notice of Medicare Provider Non-Coverage (NOMNC) ((Centers for Medicare and Medicaid Services (CMS) form CMS-10123) and a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) (form (CMS)-10055) was provided to the resident or their representative for two sampled residents (Residents #14 and #49) out of three sampled residents who were discharged from Medicare part A (insurance that covers inpatient hospital care, skilled nursing facility, lab tests, surgery, home health care for individuals who are [AGE] years of age and above or disabled). The facility census was 74 residents. Review of the undated Form Instructions for the NOMNC CMS-10123 form showed the NOMNC must be delivered at least two calendar days before Medicare coverage services end. Review of the CMS memo (S&C-09-20), dated 1/9/09, showed: -The NOMNC, form CMS-10123 is issued when all covered Medicare services end for coverage reasons. -If the SNF believes on admission or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS-a federally mandated assessment instrument completed by the facility staff for care planning) was accurate for one sampled resident (Resident #17) out of 19 sampled residents. The facility census was 74 residents. Review of the facility policy titled MDS 3.0 Care Assessment Summary and Individualized Care Plans, revised 11/6/23, showed: -Section L is used to document any dental problems. -Section L was to be completed by nursing staff. -The MDS defined the dental health of the resident and included an assessment of mouth and facial pain. -The focus of section L was the relationship between poor oral health, the quality of life, and the nutritional status of the resident. -MDS's must be kept current and up to date. 1. Review of Resident #17's clinical admission assessment, dated 4/3/24 showed: -The resident had his/her own teeth. -Observation of dental status was not assessed. -Mouth issues were not assessed. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to comprehensively assess a resident who experienced a significant change in status for one sampled resident (Resident #33) out of 19 sampled residents. The facility census was 74 residents. Review of the facility's policy titled Significant Change dated 11/6/23 showed: -The facility staff would identify within 14 days a significant change in two or more areas of decline or improvement in the resident's physical or mental condition. -If the resident showed a decline or improvement in two or more areas a significant change assessment would be completed within 14 days. -The significant change was a major decline or improvement in the resident's status that would not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions that has an impact on more than one area of the resident's health status, and requires interdisciplinary review or revision of the care plan or both. 1.…

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 properly administer medications by not having a physician's order stating the resident was able to self administer medications , failed to administer medications within the allotted time frame, and failed to ensure prescribed medications were available for one sampled resident (Resident #41) out of 19 sampled residents. The facility census was 74 residents. Review of the facility's policy, General Medication Administration Process dated 6/26/24 showed: -Keep medication cart stocked with adequate supplies. -Ensure medications were administration were followed; right time. -Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. -Observe resident consumption of medication. 1. Review of Resident #41's face sheet showed he/she was re-admitted to the facility on [DATE] with the following diagnoses: -Chronic Obstructive Pulmonary Disease (COPD a group of lung diseases that block airflow and make it…

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 follow physician's orders for obtaining Prothrombin Time (PT: a test used to help detect and diagnose a bleeding disorder or excessive clotting disorder) and International Normalized Ratio (INR: calculated from a PT result and is used to monitor how well the blood-thinning medication is working to prevent blood clots) labs for one sampled resident (Resident #17) on Coumadin (an anticoagulant) out of 19 sampled residents. The facility census was 74 residents. Review of the facility policy titled High Risk Medications Anticoagulants Policy, revised 6/26/24, showed: -Routine labs, including baseline and subsequent labs, shall be ordered for each resident requiring anticoagulation medication. -Results shall be communicated to the physician in a timely manner. -Lab results that are outside the normal limits or target range for the individual resident, but not critical values, shall be communicated to the physician within 24 hours. -Lab results that are considered critical values per facility lab specificity shall be…

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

Based on observation, interview, and record review, the facility failed to provide toenail care or an appointment with a podiatrist for one sampled resident (Resident #17) out of 19 sampled residents. The facility census was 74 residents. A podiatry policy was requested and not provided. 1. Review of Resident #17's Face Sheet showed the resident was admitted to the facility with the following diagnoses: -Morbid obesity. -Dysfunction of lower extremity. Review of the resident's admission Minimum Data Set (MDS-A federally mandated assessment tool required to be completed by facility staff for care planning) dated 4/11/24 showed the resident: -Was cognitively intact. -Required maximal/substantial assistance with personal hygiene. During an interview on 9/23/24 at 1:22 P.M. the resident said: -He/she had requested to see a podiatrist to care for his/her toenails. -He/she made this request to the previous social worker and the current administrator. -He/she had never seen a podiatrist since being in the facility. -He/she had pain in his/her feet from his/her toenails being so long.…

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 communication between the facility and dialysis (a mechanical way to filter the blood and remove waste when the kidneys stop functioning) treatment center was maintained and ongoing to ensure the continuum of care and failed to maintain and implement post dialysis assessment orders to ensure safety for one sampled resident (Resident # 38) out of 19 sampled residents. The facility census was 74 residents. A dialysis policy was requested but not received. 1. Review of Resident #38's Care Plan dated 11/15/22 showed the resident: -Had dialysis three times a week due to End Stage Renal Disease (ESRD- a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life) -Was to be monitored for any signs and symptoms of infection (redness, swelling, warmth, or drainage) to the access site by facility staff. Review of the resident's Physicians Order Sheet (POS) dated 12/29/23, 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 interview and record review, the facility failed to ensure the Medication Regimen Review (MRR) completed by the pharmacist was reviewed and responded to by the facility physician(s) for two sampled residents (Resident #19 and #45) out of 19 sampled residents. The facility census was 74 residents. Review of the facility's Medication Regimen Review Policy, dated 6/26/24, showed: -Each resident was reviewed at least once a month by a licensed pharmacist. -The MRR was a thorough evaluation of the medication regimen of a resident with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. -Review of the medical record was to prevent, identify, and resolve medication-related problems, medications errors and other recommendations. -The pharmacist communicated any irregularities to the facility physician, Director of Nursing (DON), or staff of any urgent needs. -The facility staff acted upon all recommendations according to procedure 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 observation, interview and record review, the facility failed to provide dental services to two sampled residents (Resident #33 and #51) out of 19 sampled residents. The facility census was 74 residents. Review of the facility's policy titled Dental Services dated as revised on 6/26/24 showed: -The dental needs of each resident were identified through the physical assessment and Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) assessment process and were addressed in each resident's plan of care. -The oral/dental status of the resident would be documented according to assessment findings. -Oral care and denture care would be provided for identified needs and as part of the resident's plan of care. -Referrals to a dental provider were to be made as appropriate. -The Social Services Director maintained contact information for dental service providers. -The facility would assist the resident with making dental appointments and arranging…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure documentation and monitoring for ongoing hospice care (a type of health care that focuses on comfort care of a terminally ill resident) visits and communication with hospice staff, and failed to obtain pertinent documentation of the delivery of hospice care services for one sampled resident (Resident #42) out 19 sampled residents. The facility census was 74 residents. 1. Review of Resident #42's admission Record showed he/she was admitted on [DATE] and admitted to hospice on 9/11/24 with the following diagnoses: -Dementia (a general term for a decline in mental ability resulting in memory loss) 4/16/24. -Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions) 4/16/24. -Senile degeneration of the brain (also known as Senile dementia- a mental deterioration [loss of intellectual ability] that is associated with or the characteristics of old age) 9/12/2024. Review of the resident's hospice communication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents received or were provided education for the pneumococcal (vaccine that protects against the bacteria that causes pneumonia) vaccinations for two sampled residents (Resident #24 and #325) out of five residents sampled for vaccines. The facility census was 74 residents. Review of the facility's policy, Infection Prevention and Control Program, dated 5/7/24 showed: -Residents should have been offered the pneumococcal vaccines recommended by the Centers for Disease Control upon admission, unless contraindicated or had received the vaccinations elsewhere. -Education should have been provided to the residents and or their representatives regarding the benefits and potential side effects of the immunizations prior to offering the vaccines. -Residents would have had the opportunity to refuse immunizations. -Documentation would reflect the education provided and details regarding whether the resident received the immunizations. 1. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two sampled residents (Residents #24 and #325) out of five residents sampled for vaccines were offered the Coronavirus Disease ((COVID-19) is an infectious disease caused by a virus that causes symptoms of a respiratory illness) vaccine. The facility census was 74 residents. Review of the facility's policy titled COVID-19 Vaccine: Educate and Offer dated 6/26/24 showed: -All residents would be offered the COVID-19 vaccine unless the immunization was medically contraindicated, or the resident had already been vaccinated. -If the resident already received the COVID-19 vaccine, the facility would ask for documentation of the vaccination. -The facility would provide a copy of the package insert for the COVID-19 vaccine being offered. -The facility would maintain copies of any material used to educate residents about the COVID-19 vaccine. -The resident had the option to accept or refuse the COVID-19 vaccine. -The resident would sign the consent form…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent misappropriation of approximately $1100.00 cash, taken from a wallet in a safe, which belonged to one sampled resident (Resident #1) out of seven sampled residents. The facility census was 55 residents. On 8/23/24, the facility Administration was notified of the past noncompliance which occurred on 8/1/24. Facility staff were educated on abuse and neglect policy, resident funds policy, resident rights policy and resident trusts policy. The resident's money was returned to him/her. The locks on the safe was changed and only necessary personal have access to the new code. The deficiency was corrected on 8/9/24. Review of the facility's Resident Rights policy, revised on 7/5/23 showed: -A resident had the right to manage his/her financial affairs and the facility could not require resident to deposit their personal funds with the facility. -Upon written authorization of a resident, the facility must hold, safeguard, manage and account 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 interview and record review, the facility failed to preserve one sampled resident's (Resident #3) dignity when agency Certified Nurses Aide (CNA) B slapped the resident's hand and made inappropriate comments to the resident while he/she provided incontinence care out of seven sampled residents. The facility census was 77 residents. On 4/18/24, the Administrator were notified of the past noncompliance (PNC) for an incident that occurred on 4/4/24. The facility administration had all staff including agency staff in-serviced on abuse and neglect, customer services, resident rights and dignity. The deficiency was corrected on 4/5/24. Review of the facility's policy for Resident's Rights dated 6/29/23 showed: -Every resident had the right to be treated with dignity and respect. -All staff should speak to all residents with dignity and respect. 1. Review of Resident #3's Facility admission Record showed he/she was admitted on [DATE] with the following diagnoses: -Schizoaffective disorder, bipolar type-(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 observation, interview and record review, the facility failed to ensure the safety and protective oversight for one sampled resident (Resident #5) who left the faciity on 2/15/24 around 5:02 P.M., without the knowledge of the facility staff and was gone overnight from the facility out of 10 sampled residents. The facility resident census of 62 residents. On 2/27/24, the Administrator were notified of the past noncompliance (PNC) for an incident that occurred on 2/15/24. The facility administration was notified on 2/16/24 of the resident's elopement and facility investigation of the resident elopement immediately begun on 2/16/24. In-services were provided to staff who were involved and to all staff related to resident's visual monitoring (Face checks) every hour or at least every two hours to ensure the safety and protective oversight supervision for all resident at the facility on 2/16/24 and 2/17/24. The deficiency was corrected on 2/17/24. Review of the facility's Elopement Protocol revised on 1/19/22 showed: -An elopement will be defied as anytime a resident is missing…

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 prevent further potential abuse for one sampled resident (Resident #1) when an alleged incident of abuse was not reported immediately to the Administrator or designee and Certified Nurses Aide (CNA) A continued to work his/her shift after the allegation was made. There were five sampled residents. The facility census was 71 residents. Review of the facility's policy titled Abuse and Neglect Policy dated 1/5/23 showed: -Physical abuse was categorized as purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner. -Employees are trained through orientation and ongoing training on issues related to abuse prohibition practice, such as; --Dealing with aggressive residents. --Reporting allegations without fear of reprisal. -Employees and vendors are required immediately to report any occurrences of potential mistreatment including alleged violations. -If such incidents occur after hours the Administrator or designee and Director…

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 refrigerate opened condiment containers; to prevent grease build-up on the inner range hood vent; to properly thaw potentially hazardous raw meat and to maintain the meat in a safe temperature zone, and to date opened, shelved, out-of-box food items. This deficient practice of not handling foods appropriately could potentially, promote microorganisms and bacterial growth which could adversely affect the health and well-being of the residents and staff who partook of the meals prepared by the dietary staff. The facility census was 66 residents at the time of the survey. 1. Observations on 2/5/23 between 7:03 A.M. and 8:18 A.M. in the kitchen, showed the following: -At 7:03 A.M., there was no dietary staff in the kitchen. -At 7:04 A.M., the food preparation sink contained two, ten pound, sealed, cooked packages of Beef Bottom Round Pot Roast that had a label and inscription on it that read, Keep Refrigerated. There was no water in the sink and the food items felt warm to the touch with no running water flowing…

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 notice to the resident and/or the resident's representative in writing of the residents transfer to an acute care hospital for two sampled residents (Resident #23 and #26), and to provide a notice of facility-initiated transfers and discharges within 30 days of discharge and the location to which the resident was discharged to the Office of the State Long Term Care (LTC) Ombudsman for one sampled resident (Resident #68) who was transferred on an emergency basis to an acute care hospital, out of 17 sampled residents. The facility census was 66 residents. Record review of the facility's Resident Transfer/Discharge, Immediate Discharge, and Therapeutic Leave policy, revised 7/12/22 showed: -Transfer referred to the movement of a resident from a bed in one certified facility to a bed in another certified facility when the resident expects to return to the original facility. -Discharge refers to the movement of a resident from a bed in one certified…

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 a resident had a Pre-admission Screening/Resident Review (PASRR-a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis who apply or reside in Medicaid Certified beds in a nursing facility regardless of the source of payment) level II when the DA-124 (PASRR) Level I screen (used to evaluate for the presence of psychiatric conditions to determine if a level II PASRR screening was required) showed that the resident had a qualifying psychiatric condition as required, for three sampled residents (Resident #15, #23, and #60) out of 17 sampled residents. The facility census was 66 residents. Record review of facility policy entitled PASRR Assessments and DA 124 A&B dated 4/16/2017 and revised 7/9/2021 showed: -PASRR assessment was to develop a plan of care that showed continuity from previous history of behaviors and placement. -Upon the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to develop activity care plans that were comprehensive, individualized and represented the resident's current interests and needs for three sampled residents (Resident # 64, #58, and #61) who were dependent upon staff to meet their activity needs out of 17 sampled residents. The facility census was 66 residents. Record review of the facility's Comprehensive Care Plans and Baseline Care Plans policy and procedure, revised 1/19/22 showed: -The facility must develop a comprehensive care plan within 14 days of admission for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. -A licensed nurse that has been designated by the facility administration will coordinate each assessment with the appropriate participation of health professionals. The Interdisciplinary Team (IDT) will be responsible for the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Record review of Resident #60's annual MDS dated [DATE] showed he/she was cognitively intact. During an interview on 2/5/23 at 7:11 A.M. the resident said: -He/she was not invited to his/her care plan meetings. -He/she would like the facility to include him/her in his/her care plan meetings. Record review of the resident's medical record on 2/7/23 showed no information regarding his/her care plan meetings. Based on interview and record review, the facility failed to the extent practicable, to include residents and/or their representatives in the care planning process and to conduct care plan conferences to include resident/resident representative participation for three sampled residents (Residents Resident #61, #60 and #1) out of 17 sampled residents. The facility census was 66 residents. A policy was requested but not received by the facility. 1. Record review of Resident #61's annual Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning)…

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 individualized activities for three sampled residents (Resident #61, #64 and #58) out of 17 sampled residents; and to provide daily activities for the residents who would like to participate in scheduled activities. The facility census was 66 residents. Record review of the facility's Activities policy revised 2/26/21 showed: -All residents in the facility were provided an ongoing program designed to meet, in accordance of their comprehensive assessment, their interests and their physical, mental and psycho-social well-being. -If a resident required more intensive interventions for activities, one on one activities would be provided based on their specific needs. -The activity calendar would be placed on all units and would include activities that were appropriate for the population that met specific needs, cognitive impairments, and interests. -The Life Enrichment Director would monitor large group, small group, one on one…

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 restorative services were provided to maintain, improve, or prevent decline in Range of Motion (ROM the range on which a joint can move) for three sampled residents (Resident #61, #2 and #1) out of 17 sampled residents. The facility census was 66 residents. A policy was requested but not received by the facility. 1. Record review of Resident #61's admission Record showed: -The resident had a diagnosis of Cerebral Palsy (a group of neurological disorders that appear in infancy or early childhood and permanently affect body movement and muscle coordination). -Quadriplegia (paralysis of all four extremities and usually the trunk). Record review of the resident's annual Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning) dated 11/22/22 showed the resident: -Was moderately cognitively impaired. -Had limited lower extremity ROM. -Had no limitations of ROM to the upper…

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 catheter (a tube inserted into the bladder to drain urine) bags (the urine collection device) and tubing (the clear tubing extending from the end of the catheter to the collection bag) off the floor for two sampled residents with catheters (Resident #26 and #27); to ensure a physician's order with a diagnosis for one sampled resident's catheter (Resident #26); and to ensure one sampled resident (Resident #15) had his/her suprapubic catheter (a urinary bladder catheter inserted through the skin about one inch above the symphysis pubis) changed per the physician's order out of 17 sampled residents. The facility census was 66 residents. Record review of the facility Urinary Catheter Care policy, revised 2/26/21 showed: -The facility would ensure urinary catheters were maintained to prevent infection. -Residents with urinary catheters would have a physician's order for the catheter, care of the catheter and the diagnosis 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.

Based on observation and interview, the facility failed to post the actual hours worked for Registered Nurses (RN's), Licensed Practical Nurses (LPN's), Certified Medication Technicians (CMT's), and Certified Nursing Assistants (CNA's) directly responsible for resident care per shift and the resident census. The facility census was 66 residents. 1. Observation on the following dates, and times showed posted staffing did not include actual hours worked for RN's, LPN's, CMT's, and CNA's and did not include the resident census: -On 2/5/23 at 5:24 A.M. - On 2/6/23 at 10:43 A.M. -On 2/7/23 at 10:08 A.M. -On 2/8/23 at 12:16 P.M. During an interview on 2/9/23 at 2:04 P.M. the Director of Nursing (DON) said: -He/she did not know who was responsible for posting staffing hours and resident census. -He/she did not know where staffing hours and census was posted in facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure monthly pharmacy Medication Regimen Reviews (MRR-a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medications) were completed and in the resident's medical record for five sampled residents (Resident's #37, #49, #47, #62, and #34) out of 17 sampled residents. The facility census was 66 residents. Record review of facility policy titled Monthly Drug Regimen Review dated 7/5/22 showed: -The nurse/Director of Nursing (DON) will forward the pharmacists recommendations to the attending physician within 48 hours of receiving the recommendation. The nurse/DON will document the date and time that the physician was notified of the recommendation. -It the attending physician does not respond to the recommendation with 7 days, the nurse/DON will follow up with the physician to obtain orders if necessary. -The attending…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a Pro Re Nata (PRN-as needed) antianxiety medication (a controlled substance medicine that calm and relax people with excessive anxiety, nervousness, or tension) was not ordered for more than fourteen days without physician assessment for one sampled resident (Resident #34); to ensure the physician responded to a pharmacist recommendation related to a antipsychotic medications (a group of psychoactive drugs (pertaining to a drug or other agent that affects such normal mental functioning as mood, behavior, or thinking processes) commonly but not exclusively used to treat psychosis) for one sampled resident (Resident #7); and to adequately monitor for adverse consequences with use of psychotropic medication (medication that affects how the brain works and causes changes in mood, awareness, thoughts feelings and behavior) and adequately monitor behaviors with use of psychotropic medications on one sampled resident (resident #47) out of 17 sampled…

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 document that a transfer of the resident was necessary for two sampled residents (Resident #23 and #26) who were transferred to an acute care hospital, out of 17 sampled residents. The facility census was 66 residents. Record review of the facility Resident Transfer/Discharge, Immediate Discharge, and Therapeutic Leave policy revised 7/12/22 showed when a resident was transferred or discharged , the reason for the transfer/discharge must be documented in the resident's medical record. 1. Record review of Resident #23's Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning) tracking records (records of admission/discharge) showed he/she was discharged , return anticipated on 10/21/22. Record review of the resident's medical record showed the reason for the resident's discharge on [DATE] was not documented. Record review of the resident's MDS tracking records showed he/she was readmitted…

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 the bed hold policy for two sampled residents (Resident #23 and #26) who were transferred to an acute care hospital, out of 17 sampled residents. The facility census was 66 residents. Record review of the facility Resident Transfer/Discharge, Immediate Discharge, and Therapeutic Leave policy revised 7/12/22 showed: -When a resident was transferred to the hospital or other location the facility must provide to the resident or their representative a written copy of the bed hold policy. -This notice must be given at the time of transfer. -For emergency transfers the bed hold notice must be given within 24 hours of transfer. -If the emergency transfer was to a hospital, the facility may send a copy of the bed hold policy to the resident in the hospital if a hospital representative such as a social worker. 1. Record review of Resident #23's Minimum Data Set (MDS a federally mandated…

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 comprehensive falls investigations, determine a root cause (main cause) for the resident's falls and revise the resident's care plan following a fall for one sampled resident (Resident #26) out of 17 sampled residents. The facility resident census was 66 residents. Record review of the facility Focused Risk Assessment Plan Scope/Severity for Falls (FRAPSS) policy revised 7/9/23 showed: -The purpose of the policy included identifying precipitation factors for fall risk and to be proactive in implementing interventions to prevent or reduce further falls. -Residents will be assessed using the FRAPSS including in an acute situation where a resident has had a fall. -The FRAPSS assessment guide measures areas of precipitating factors, history of previous falls, sensory deficits, medications and resident compliance. -The resident will be assessed by a Licensed Nurse and after the assessment is completed the resident will be scored accordingly and placed on the scope and severity level which outlines the plan of care and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide ongoing assessment of the resident's condition and monitoring for complications before and after hemodialysis (a procedure involving diverting blood into an external machine, where it is filtered before being returned to the body to remove waste products and excess fluid from the blood when the kidneys stop working properly) treatments by having a licensed nurse assess the dialysis site for one sampled resident (Resident #49) out of 17 sampled residents. The facility census was 66 residents. Record review of the facility policy entitled Dialysis dated 11/28/17 and revised 3/18/22 showed: -Ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. -Ongoing assessment and oversight of the resident before and after dialysis treatments. -Coordination of Physician Services between Nursing Home and Dialysis facility. -For a resident 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 observation, interview and record review, the facility failed to identify, assess and provide supportive interventions for one sampled resident (Resident #60), with a diagnosis of Post-Traumatic Stress Disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event), out of 17 sampled residents. The facility census was 66 residents. Record review of Trauma-Informed Care Implementation Center (https://www.traumainformedcare.chcs.org/what-is-trauma-informed-care/) copyright 2021 showed: -Trauma-informed care shifts the focus from What's wrong with you? to What happened to you? -A trauma-informed approach to care acknowledges that health care organizations and care teams need to have a complete picture of a patient's life situation - past and present - in order to provide effective health care services with a healing orientation. -Adopting…

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 dental services for one sampled resident (Resident #7) with teeth in poor repair out of 17 sampled residents. The facility census was 66 residents. A policy was requested but not received. 1. Record review of Resident #7's admission Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning) dated 12/17/21 showed the resident: -Was cognitively intact. -Had teeth in good repair. Record review of the resident's annual MDS dated [DATE] showed the resident: -Was cognitively intact. -Was independent with Activities of Daily Living (ADLs-grooming, hygiene, self-care). -Was edentulous or had broken/fragmented teeth. Record review of the resident's care plan dated 12/16/22 showed the resident was independent with self-care and staff would monitor. Observation and interview on 2/5/23 at 7:45 A.M. showed: -The resident had all front lower teeth broken off at the gum line. -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 infection control practices were implemented to ensure no cross contamination was performed when two sampled residents' catheter bags (a flexible tube inserted through a narrow opening into the bladder, drains into a collection bag for removing fluid from the body) were on the floor (Resident #6 and #20); to ensure proper hand hygiene during catheter care for one sample resident (Resident #1) and during the transfer of one resident (Resident #20); to ensure proper storage of breathing tubing and masks when not in use for two sampled resident residents (Resident #32 and #33); and to include the following in its waterborne illness plan: a risk assessment of where opportunistic waterborne pathogens (e.g. Legionella sp. (a form of pneumonia, caused by the bacterium Legionella pneumophila found in both potable and nonpotable water systems, Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, and fungi) could grow and spread in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to do the following: maintain the fan in Resident #33's room free of a heavy buildup of dust; maintain the backing support of the shower chair free of large rips, failed to maintain the shower mat in the 500 Hall shower room free of rips and tears which caused it to be not easily cleanable; failed to maintain the brakes of the wheelchairs that belonged to Residents #45 and #25 in working order; and failed to maintain the restroom ceiling vent in resident room [ROOM NUMBER] free of a heavy buildup of dust. This practice potentially affected at least 40 residents who used or resided in those areas. The facility census was 48 residents. 1. Observations with the Environmental Services Director and the Maintenance Director on 3/3/20, showed the following: - At 8:58 A.M., there was a heavy buildup of dust on the fan in Resident #33's room. - At 9:00 A.M., Resident #33 said facility staff had not cleaned his/her fan. - At 9:00 A.M., The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the medication refrigerator temperature was monitored and maintained within the appropriate range for the refrigerated medications and vaccines. The refrigerator temperature was 52 degrees Fahrenheit (°F) Affecting a total of 85 medications including insulin, vaccine, antipsychotics and anti-anxiety medications. Two sampled residents (Resident #1 and #2) had been given medication out of that refrigerator that day. There were 13 sampled and 8 supplemental residents. The facility census was 48 residents. Record review of the manufacturers package insert for Desmopressin AC (used to increase urine concentration and decrease urine production) revised in July 2007 showed: -Store in refrigerator between 36 °F and 46 °F. Record review of the Manufacturers package insert from AbbVie Inc revised in August 2017 showed: -Store Dronabinol (marinol used to stimulate the appetite and decrease nausea) in a cool place such as in a refrigerator, 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 ensure residents' dignity by not placing a privacy bag over the catheter bag for three sampled residents (Residents #6, #20, and #37) out of 13 sampled residents. The facility census was 48 residents. 1. Record review of Resident #6's Face Sheet showed he/she was admitted on [DATE] with diagnoses including respiratory failure, pneumonia, stroke, seizures, dysphagia (difficulty swallowing), high blood pressure, history of urinary tract infection and neurogenic bladder (lack of bladder control) with urinary retention. Record review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment tool to be completed by facility staff for care planning) dated 3/3/20, showed he/she: -Was alert, but had cognitive difficulty and memory problems. -Was totally dependent on staff for transfers, mobility, bathing, dressing, toileting and grooming. -Was incontinent and used a catheter for urination. Observation on 3/5/20 at 9:07…

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 obtain an authorization from for the facility to hold and manage resident funds for one sampled resident(Resident #31) and to implement a system to ensure receipts were retrieved by the Business Office, after the resident's family member withdrew money from the resident's fund account, for expenses. This practice potentially affected one resident out of four residents sampled for the purpose of reviewing the resident fund's process at the facility. The facility census was 48 residents. 1. Record review of the authorization forms showed the absence of a signed authorization for Resident #31. During an interview on 3/2/20 at 12:41 P.M., the Business Office Manager (BOM) said: - Resident #31 signed up for the account in September of 2019. -The resident was physically and mentally unable to sign the authorization form. -The resident's family member is the Durable Power of Attorney (DPOA- a trusted person who a resident may choose to act in that resident's place for medical care and finances if that resident became mentally…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the code status (instructions on what to do in case of cardiac or respiratory arrest) for one sampled resident (Resident #146) was transcribed to the resident's Physician Order Sheet (POS) out of of 13 sampled residents. The facility census was 48 residents. 1. Record review of Resident #146's Face Sheet showed he/she was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including brain injury, neck fracture, right femur fracture, left shoulder fracture, respiratory failure, dysphagia (difficulty swallowing), pneumonia, gastronomy (a tube that is placed directly into the stomach for long term administration of food, fluids, and medications) and tracheostomy (the surgical formation of an opening into the trachea through the neck especially to allow the passage of air). Record review of the resident's Hospital Discharge Record dated 2/26/20, showed hospital physician discussed with the resident's responsible party 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 the care plans were comprehensive and updated to reflect the current status with interventions needed for one sampled resident (Resident #1) with and indwelling catheter (Foley catheter, a sterile tube that is inserted into the bladder to drain urine) out of 13 sampled residents. The facility census was 48 residents. 1. Record review of Resident #1's admission Face Sheet showed he/she had been admitted to the facility on [DATE] with diagnoses of: -Pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) of sacral region (large, triangular bone at the base of the spine and at the upper and back part of the pelvic cavity), Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunnelling). -Chronic…

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 equipment for maintaining or improving range of motion was available for one sampled resident (Resident #20) out of 13 sampled residents. The facility census was 48 residents. Record review of Resident #20's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -History of brain hemorrhage (an emergency condition in which a rupture blood vessel causes bleeding inside the brain). -Other lack of coordination. -Hemiplegia (paralysis) and hemiparesis (slight paralysis/weakness) affecting the right side of the body following brain hemorrhage. -Generalized muscle weakness. Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 1/8/20 showed he/she had functional limitations in range of motion on his/her upper and lower extremities on one side. Record review of the resident's February 2020…

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 a safe transfer for two sampled residents (Residents #38 and #15), and to ensure the accuracy of assessments and care planning related to safe transfer for one sampled resident (Resident #15) out of 13 sampled residents. The facility census was 48 residents. 1. Record review of Resident #38's Face Sheet showed he/she was admitted to the facility on [DATE], with diagnoses including anxiety, muscle spasms, deformity of the lower leg, and cervical spondylosis (wear and tear affecting the spinal disks in your neck). Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 2/4/19, showed he/she: -Was cognitively intact. -Needed limited assistance with bathing, dressing, toileting, and transferring. -Was not stable to transfer from surface to surface without assistance. -Used a wheelchair to mobilize. Record review of the resident's Care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to obtain a physician's order for a resident to self-administrator his/her medications; to assess the resident ability to be able to self-administer medication and to ensure to update the resident respiratory care plan to reflect current health status for one sampled resident (Resident #33) out of 13 sampled resident. The facility census was 48 residents. 1. Record review of Resident #33 admission Face Sheet showed he/she was readmitted to the facility on [DATE] with diagnoses of: -Chronic Obstructive Pulmonary Disease (COPD - a disease process that decreases the ability of the lungs to perform ventilation). -Congestive Heart Failure (disorder that impairs the ability of the heart to fill with or pump a sufficient amount of blood throughout the body). -The resident was his/her own responsible person. Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility 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.

Based on observation, interview and record review, the facility failed to ensure a dead mouse and mouse droppings (the excrement of certain animals, such as rodents, sheep, birds, and insects) were removed from the kitchen furnace room for three days of the survey. This practice potentially affected one non-resident use area. The facility census was 48 residents. 1. Observations on 3/2/20 at 8:29 A.M., 3/3/20 at 10:23 A.M. and 3/4/20 at 8:27 A.M., showed the presence of a dead mouse and mouse droppings in the kitchen furnace room. During an interview on 3/3/20 at 10:22 A.M., the Maintenance Director said he/she did not know about the dead mouse in the kitchen furnace room. During an interview on 3/4/20 at 8:28 A.M., the Dietary Manager (DM) said he/she had not seen the mouse and the mouse droppings in the dietary furnace room. Record review of the 1999 and 2009 Food and Drug Administration (FDA) Food Code and Missouri Food Codes, showed: 6-501.111 Controlling Pests. The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, 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.