Shirkey Nursing And Rehabilitation Center

Based on observations, interviews, and facility policy review, the facility failed to keep the scoops out of food storage bins and ensure stored food was dated. This had the potential to affect 86 of 86 residents who resided in the facility and consumed food prepared from the facility's kitchen. Review of the facility's undated policy titled Resident Food Storage, revealed 1 .Food or beverages brought into the facility for resident consumption will be labeled and dated for monitoring food safety. Food or beverages in the original container marked with manufacturer expiration dates and unopened do not have to be re-labeled for storage During an initial tour of the kitchen on 04/02/24 at 8:55 AM, with the Dietary Manager (DM), the following observations were made: Dry Storage and kitchen: a. One 5-pound bag, containing yellow cake mix, was observed open and undated. b. A large clear container labeled, containing thickener, were observed with scoops lying in the thickener. The thickener was also undated. Interview on 4/03/24 at 8:55 AM, DM stated scoops should not be kept in 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 interview and record review, the facility failed to have the Medical Director and/or designee attend the last two quarterly QAPI (Quality Assurance and Performance Improvement) committee meetings. Review of the 11/28/23 QAPI sign-in sheet for the quarterly meeting revealed the Medical Director did not attend and was marked, unable to attend. Review of the 02/20/24 QAPI sign-in sheet for the quarterly meeting revealed the Medical Director did not attend and was marked as, unable to attend. During an interview on 04/05/24 at 11:53 AM, the QAPI Nurse was asked if the Medical Director or their designee attended the quarterly meetings. The QAPI Nurse stated, He does attend the meetings, but not the last ones. The QAPI Nurse was asked if she was aware that the Medical Director or their designee are to attend the meetings, as required in the regulation. She stated, Yes.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of facility policy, the facility failed to ensure resident Care Plans were updated/revised for two residents (Residents (R) 84, R6) of 21 sampled residents. The facility failed to update the Care Plan for R84 related to her behaviors and oxygen usage for R6. This failure created an increased risk for the residents to care and services that may not be appropriate for their current clinical condition. Review of the facility policy titled, Updating Care Plans, dated 04/05/18 revealed, . Care Plans need to be continually updated as the resident's needs change. The Care Plan needs to reflect the resident's current status at any given moment . 1. Review of the Face Sheet located in the Face Sheet tab of the electronic medical record (EMR) revealed R84 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. Review of the admission Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) 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 provide showers to two residents who preferred showers (Residents (R)8, and R73) of five residents reviewed in a total sample of 21 residents. This failure placed the residents at risk of a diminished quality of life. Findings include: 1. Review of the Face Sheet located in the Face Sheet tab of the electronic medical record (EMR) revealed R8 was admitted to the facility 03/01/10 with diagnoses that included Parkinson's disease (a progressive neurological disorder), dementia, and anxiety. Review of the quarterly Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 02/06/24 revealed R8 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15 which indicated she was cognitively intact for daily decision-making. In addition, the assessment revealed she required substantial assistance with showering. Review of an 01/22/19 ADL [activities of daily living] Care Plan, revised on 11/16/23 which was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff and family interviews, and facility policy review, the facility failed to (1) assess resident (R) 23's falls, monitor the effectiveness of the interventions, or modify the interventions to prevent further falls and/or injuries for one of three residents reviewed for falls (R23, R46, and R57); (2) provide a fire blanket and fire extinguisher in the three designated resident smoking areas to reduce the risk of harm for the three residents who smoke (R26, R30, and R42); and (3) to conduct a smoking assessment for one of three residents (R)26, to determine independent versus supervised smoking needs. 1. Review of the facility's 2006 policy titled, Unusual Occurrences, provided by the Administrator, revealed the following: All incidents will require that an incident report be filled out by the charge nurse. Incidents are falls, bruises, skin tears and anything that the charge nurse would consider an unusual occurrence. Once the incident report is complete . the coordinator…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review and facility policy review, the facility failed to: have a system in place to ensure respiratory equipment to include oxygen tubing was dated/labeled when changed out, failed to ensure documentation of cleansing of C-pap masks(Continuous positive airway pressure- a form of positive airway pressure that is continuously applied to the upper respiratory tract of a person), C-pap tubing, and water chamber were being cleaned and changed as per physician orders on Sundays, failed to ensure a C-pap machine was kept off the floor, and failed to have clean oxygen filters, maintain oxygen in the nose, and apply oxygen continuously for two of two residents (Resident (R) 51 and R48) reviewed for respiratory therapy out of a total sample of 21 residents. This failure placed the residents at risk for respiratory illnesses, and further increased the risk of contamination of the respiratory equipment. Review of the facility's untitled policy, dated 02/28/2019and provided by the…

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

Based on observations, interviews, record reviews, and review of the facility assessment, the facility failed to ensure sufficient nurse staffing to meet the needs of the residents resulting in residents not receiving showers for two (Residents (R) 73, R8) of five sampled residents, activities to meet residents' needs in the secured dementia unit. These failures placed residents at risk of a diminished quality of life and potential unmet care needs. 1. This tag is cross-referenced to F676; ADL [maintain activities of daily living] as not diminish or decline. Based on interview and record review, including shower schedules, the facility failed to consistently provide showers for R73, and R8. Review of the quarterly Minimum Data Set (MDS) located in the MDS tab of the electronic medical record (EMR) with an Assessment Reference Date (ARD) of 02/06/24 revealed R8 was cognitively intact for daily decision-making. During an interview on 04/02/24 at 12:15 PM, R8 stated, I am to get two showers [her choice of bathing] per week .I haven't had a shower since last Tuesday [lapse of seven…

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 complete an Abnormal Involuntary Movement Scale [AIMS-a test that rates involuntary muscle movements (tardive dyskinesia) on residents who are administered antipsychotic medications] assessment for two residents (Resident (R) 65 and R84) and failed to re-evaluate the need for an antipsychotic medication for one resident (R4) of five residents reviewed for unnecessary medications in a total sample of 21. These failures placed residents at risk for unrecognized side effects. 1. Review of the Face Sheet located in the Face Sheet tab of the electronic medical record (EMR) revealed R65 was admitted to the facility on [DATE] with diagnoses that included heart failure, diabetes, and pulmonary disease. Review of a 10/24/23 Psychotropic Medication Change Progress Note, located in the Progress Notes tab of the EMR and recorded as a late entry on 11/07/23, revealed NEW ORDER: Seroquel [an antipsychotic medication] 12.5 mg at bedtime for increased behaviors,…

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

During an observation, interview, and review of facility policy, the facility failed to prepare, store, and label medications according to standard nursing practice for one of four Certified Medication Aide (Certified Medication Aide (CMA3) observed during medication pass. This failure placed prescription-based medications readily accessible to residents, increased health complications, and the possibility of giving the wrong medication to the wrong resident. Review of an untitled facility policy, dated 04/29/14, revealed, Medication is never to be left unattended. If you must leave your cart, then all medications are to be locked inside. During a medication pass observation on 04/05/24 at 7:40 AM, Medication cart 5 [NAME] was parked outside a room. CMA3 was not stationed at the cart but was in a resident's room. The cart showed that there were three individual plastic cups on top of the cart which were observed to contain powder mixed in liquid, which had gelled at the bottom of the cup. Inside each cup was a plastic spoon. The individual cups were not labeled. CMA 3 returned 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 employee record review and interviews, the facility failed to have documentation of completion of a minimum of 12 hours of required in-service training to include Dementia care and Abuse, Neglect, and Exploitation for five of five Certified Nursing Assistants (CNAs) (CNA 1, 2, 4, 6, and 7). By not ensuring employees are meeting the required trainings and in-services, residents may be at risk and unable to get their needs met. Review of the facility's Facility Assessment updated February 28, 2024, indicated, Staff Education: Orientation, Annual: Required annual education/training (minimum of 12 hours annually for Nursing Assistants) . During an interview on 04/04/24 at 9:52 AM, CNA1 was asked about trainings and in-services on dementia care and abuse and neglect. CNA1 stated, We have annual in-services, and we cover abuse and neglect. When specifically asked about dementia care, the CNA stated, Prior to coming here, I got trainings, but not really here. No, I don't believe so. During an interview on 04/04/24 at 9:55 AM, CNA7 was asked about annual trainings on abuse, neglect…

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 one resident and/or representative (Resident (R) 65) of five residents reviewed for unnecessary medications out of a total sample of 21 residents was informed of the risk and benefits of physician ordered psychotropic medications. This failure placed the resident and/or representative at risk of not knowing the risks and benefits of the use of the medications. Review of the Face Sheet, located in the Face Sheet tab of the electronic medical record (EMR), revealed R65 was admitted to the facility on [DATE] with diabetes, heart failure, and chronic obstructive pulmonary disease (COPD). Review of the significant change Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 11/07/23 revealed, R65 had a Brief Interview of Mental Status (BIMS) of 14 out of 15 which indicated she was cognitively intact for daily decision-making. Review of a 10/24/23 Psychotropic Medication Change [Recorded as Late Entry on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of facility policy, the facility failed to investigate an injury of unknown source for one resident (Resident (R) 65) of one resident reviewed in a total sample of 21. This failure to investigate a fractured leg placed the resident at risk for potential abuse. Review of the facility policy titled, Policy and Procedure Regarding Investigation and Reporting of Alleged Violation of Federal and State Laws involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source and Misappropriation of Residents property, dated 11/20/03 revealed, Investigation: All investigations shall be conducted by the Administrator or DNS (Director of Nursing Services) .The investigation shall include interviews of employee's, visitors or residents who may have knowledge of the alleged incident .Written statements from involved parties should be requested .The medical record should be reviewed to determine the resident's past history and condition and its relevance to 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 consistently provide a program of meaningful activities in accordance with the resident's preferences for one resident (R84) of nine residents reviewed for activities in the secured dementia unit out of a total sample of 21 residents. This failure placed R84 at risk of a diminished quality of life. Review of the Face Sheet located in the Face Sheet tab of the electronic medical record (EMR) revealed R84 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. Review of the admission Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date of 02/27/24 revealed R84 had a Brief Interview of Mental Status (BIMS) score of four out of 15 which indicated she was severely impaired in cognition. In addition, her staff assessed activity preferences revealed R84 liked to spend time away from the nursing home, doing her favorite activities including religious activities. Review of the 04/01/24…

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 of four Certified Medication Aide (Certified Medication Aide (CMA) 3) observed during medication pass, had the skills and competency to safely perform medication administration. Refer to F761. Review of the Staff Roster provided by the Director of Nursing (DON) revealed CMA 3 was hired by the facility on 07/11/02. Review of the 2023 and 2024 Skills and Drills sheet provided by Licensed Practical Nurse (LPN) 5 showed CMA 3 had not been assessed for medication competency since 04/11/23. The Skills and Drills sheet further revealed that CMA 3 was only observed for insulin, eye drops, and inhalers and had not been assessed for any other medication pass requirements. During an interview on 04/05/24 at 10:39 AM LPN 5 confirmed that CMA 3 had not been assessed for competency since 2023 and that overall medication pass observation had not been done.

Based on observations, interviews, and record reviews the facility failed to assure staff treated two sampled residents (Residents #44 and #18) in a manner that maintained their psychosocial well being and dignity when staff treated one resident (Resident #44) rudely. The facility census was 95. The facility did not provide a policy on dignity. Review of Resident #44 admission Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff ) dated 2/8/22 showed: -Brief Interview of Mental Status (BIMS) of 15 (indicates no cognitive impairment); -No exhibited behaviors; -Resident able to understand and make self understood. Review of Resident #44 Face Sheet showed diagnosis of: -Diabetes Mellitus (a disorder in which the body does not produce enough or respond normally to insulin, causing blood sugar (glucose) levels to be abnormally high) with neuropathy(damage to the nerves located outside of the brain and spinal cord that often causes weakness, numbness and pain, usually in the hands and feet); -Hypertension; -History of Myocardial Infarction (also known as…

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 personal funds and a final accounting within thirty days upon discharge. This affected 3 additional residents (Residents #247, #248, and #250). the facility census was 95. Review of the undated facility policy for Resident Trust Funds showed: -If a patient leaves, the funds are disbursed to the patient. -If a patient passes away, a funds report is emailed to mhd.costrecovery.dss.mo.gov. (A program that states any open estate may not be closed with respect to a decedent who, at the time of death, was enrolled in MO HealthNet until a release of the Estate Recovery Claim by MO HealthNet is obtained.) Response from this program will determine where money will be refunded. Refund within 3 days of response. Review of the facility's Aging Report dated 3/31/2022 showed the following residents had money in the facility's operating account: -Resident #248 discharged [DATE]: $75.28 -Resident #250 discharged [DATE]: $487.81 -Resident #247 discharged…

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

Based on record review and interviews, the facility failed to purchase a surety bond in a sufficient amount to ensure the security of all residents' personal funds deposited with the facility. The facility census was 95. Review of the undated facility policy for Resident Trust Funds showed: -There was no mention of maintaining a surety bond. Review of the facility's surety bond dated 3/30/2017, showed a bond amount of $9,000.00. Review of the Residents Funds Worksheet on 4/13/2022, completed with the last twelve months of reconciled bank statements and petty cash amounts showed the required bond amount needed was $21,000.00. During an interview on 4/13/2022 at 10:41 A.M , the Business Office Manager (BOM) said: -He/she is aware the bond amount is not high enough. The resident's stimulus money has increased the required amount of the bond. -He/she has contacted the surety company this week, notifying them the need to increase the bond. During an interview on 4/19/2022 at 3:33 P.M., the Administrator said: -He/she is aware the bond amount needs to be high enough to cover 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 and comfortable homelike environment. This had the potential to affect all residents. The facility census was 95 1. Observation on 4/11/22 beginning at 11:00 A.M. showed the following in the following rooms: - #616- Beach ball brown stain on a ceiling tile in the bathroom, ceiling tile sagging; - #621- Four ceiling tiles with brown stains varying in size from a softball to beach ball; - #619- Two cantaloupe size stains on a ceiling tile and one watermelon sized stain in bathroom; - #320- Cantaloupe sized stain on a ceiling tile; - #318, 3 stained ceiling tiles of various sizes up to the size of a beach ball, one beach ball sized stain on the ceiling in the shared bathroom; - #315- 2 beach ball stains on the ceiling tiles; - #312- Missing ceiling light cover in the shared bathroom; - #311- Watermelon sized stain on the ceiling; - #204- Multiple stains of the ceiling of various sizes; 2. During an interview on 4/14/22 at 10:27 A.M.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure staff provided a written notice of transfer or discharge to residents and their representative, including the reason for the transfer, in writing and in a language they understood. This affected three of 19 sampled residents, (Resident #28, #74 and #97). The facility census was 94. The facility did not provide a policy for transfers and discharges. 1. Review of Resident #28's significant change in status Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/25/22, showed: - Cognitive skills severely impaired; - Dependent on the assistance of two staff for bed mobility, transfers, and dressing; - Dependent on the assistance of one staff for toilet use; - Upper and lower extremities impaired on both sides; - Had a supra pubic catheter (enters the bladder through the lower abdomen); - Had a colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in 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 inform the resident and the resident's family/legal representative of the facility's bed hold policy at the time of transfer/discharge to the hospital for three of 19 sampled residents, ( Resident #28, #74 and #97). The facility census was 94. Review of the facility's undated bed hold policy, showed, in part: - The resident may need to be absent from the facility temporarily for hospitalization or therapeutic leave. The resident may request that the facility hold open the resident's bed during this time. This is known as bed hold. The resident and a family member or legal representative shall be given notice of the bed hold option at the time of hospitalization or therapeutic leave; - Medicaid residents - if the resident's care is paid under the Medicaid program, the facility will allow 12 grace days every six months for hospitalization, therefore there will be no charge to hold the room. These days do not carry over and this policy will be based on a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure staff met as an interdisciplinary team with the resident and/or representative to establish and provide the resident a baseline or 48 hour care plan for one of 19 sampled residents, (Resident #147). The facility census was 94. The facility did not provide a policy for baseline care plans. 1. Review of Resident #147's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/7/22, showed: - Cognitive skills intact; - Required extensive assistance of two staff for bed mobility, transfers, dressing, and toilet use; - Lower extremity impaired on one side; - Always continent of bowel and bladder; - Diagnoses included anemia (a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues), coronary artery disease (CAD, a narrowing or blockage of the coronary arteries), high blood pressure, hip fracture and depression. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure they developed and implemented a comprehensive person-centered plan of care which included measurable objectives and timeframe's to meet each resident's medical, nursing, and mental psychosocial needs identified in the comprehensive assessment for eight of 19 sampled residents, ( Resident #28, #74, /#23, #56 #80, #15, 24 and #33). The facility census was 94. Review of the facility's policy for care plan, dated 7/30/07, showed: - It is very important to know exactly how to care for the residents. The care plan is a tool to aide all nursing staff on how to do just that: all nursing staff need to know where the care plans are located on the wing; all nursing staff need to know that they have access to the care plans; all nursing staff need to know that it is their responsibility to know the information contained in the care plan; all nursing staff need to know that is is their responsibility to imitate or implement interventions 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 observations, interviews, and record review, the facility failed to ensure staff provided services that met professional standards of quality of care when staff failed to obtain a physician's order for a surgical wound treatment for one of 19 sampled residents, ( Resident #147) and failed to notify the physician of significant weight loss for one resident (Resident #56). The facility census was 94. The facility did not provide a policy for following physician's orders or notification of physician. 1. Resident #147 was admitted on [DATE] and did not have a baseline care plan. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/7/22 showed: - Cognitive skills intact; - Required extensive assistance of two staff for bed mobility, transfers, dressing and toilet use; - Lower extremity impaired on one side; - Diagnoses include hip fracture, anemia (a condition in which you lack enough healthy red blood cells to carry…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff did not provide complete perineal care which affected three of 19 sampled residents, (Resident #36, #74 and #147), and when staff failed to provide morning care such as oral care and comb/brush Resident #74's hair. The facility failed to provide assistance for one resident (Resident #18) in a timely manner, when the resident asked for assistance in using the bathroom. The facility census was 94. Review of the facility's policy for male peri care, dated 3/29/19, showed: - Wash the lower abdomen, groin area and inner legs; - Using a circular motion wash the skin fold from the tip down; - The uncircumcised resident must have the skin fold retracted (pulled back) first; - Wash all the skin folds; - Replace the skin fold; - Turn the resident on his/her side; - Wash the back 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 observations, interviews, and record review, the facility failed to ensure staff used proper techniques to reduce the possibility of accidents or injuries when transferring two of 19 sampled residents, (Resident #36 and #74) with the mechanical lift ; and use of a damaged sling to transfer one resident (Resident #18) from bed to chair. The facility census was 94. Review of the undated manufacturer's guidelines for the Invacare Reliant 450 mechanical lift, showed: - When using the adjustable base lift, the legs MUST be in the maximum opened/locked position before lifting the resident; - Invacare does not recommend locking of the rear casters of the resident lift when lifting an individual. Doing so could cause the lift to tip and endanger the resident and assistants. Review of the facility's policy for electric Hoyer lift transfer, dated 5/12/17, showed, in part: - The purpose is to transfer the resident safely with the help of two staff members. One staff member to operate the lift and the other 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to assure staff provided proper respiratory care when staff failed to date oxygen tubing for one of 19 sampled residents, (Resident #74) and failed ensure physician orders were in place for one resident (Resident #70) using oxygen. The facility census was 94. Review of the facility's policy for oxygen use, dated 2/28/19, showed: - All oxygen concentrator filters need to be cleaned every week on Sunday night. Even concentrators that are not being used; - Oxygen tubing must be changed weekly and dated; - Oxygen tubing and nebulizer tubing must be stored in a plastic bag. 1. Review of Resident #74's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 3/22/22 showed: - Cognitive skills intact; - Diagnoses included anemia (a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues), CHF, anxiety, depression and dementia. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure that staff provided adequate pain control for two sampled residents (Resident #7 and Resident# 44). The facility census was 95. The facility did not provide a policy regarding pain management. 1. Review of Resident #7's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 3/22/22, showed: -Scored 3 out of 15 on the Brief Interview for Mental Status (BIMS) (a screen used to assist with identifying a resident's current cognition and to help determine if any interventions need to occur.) A score of 3 indicates severe cognitive impairment. -Adequate hearing /vision, is able to make self understood and understand others. -He/she requires extensive assistance with activities of daily living(ADL's), including, dressing, toileting, personal hygiene. -He/she is frequently incontinent of bladder, and is occasionally incontinent of bowel. -He/she is not receiving scheduled or as needed pain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure communication between the facility and dialysis center and standards of practice when staff failed to document assessments of one resident (Resident #15) before and after dialysis. The facility census was 95. The facility did not have a policy for dialysis. 1. Review of the medical record for Resident #15 dated 3/1/21 showed: -Dialysis orders read: Start date 3/1/2021, Resident to go to outside dialysis clinic for dialysis Monday, Wednesday and Friday per week. Check bruit and thrill to left forearm shunt daily. If not present call the physician at the dialysis clinic. Review of the quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 3/29/22, showed: -Five out of 15 on the Brief Interview for Mental Status (BIMS), a screen used to assist with identifying a resident's current cognition and to help determine if any interventions need to occur. A score of 5 indicates severe cognitive impairment.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to communicate the consultant pharmacist's recommendations to the resident's physicians for four of 19 sampled residents, (Resident #4, #36, #74 and #147) and failed to provide a rationale when the recommendation was declined which affected Resident #147. The facility census was 94. The facility did not provide a policy for drug regimen reviews. 1. Review of Resident #147's Drug Regimen Review (DRR), dated 2/2/22 showed the consultant pharmacist recommended: - The resident is [AGE] years old and takes citalopram 40 milligrams (mg.) for depression. The is medication is recommended to not exceed 20 mg. per day in people greater than [AGE] years old due to increased risk of QT prolongation (the time it takes the ventricles of the heart to contract and relax); - On 4/18/22 the Family Nurse Practitioner Certified (FNPC) checked disagree but failed to provide a rationale. Review of the resident's DRR, dated 4/2/22 showed the consultant pharmacist recommended:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure PRN (as needed) psychotropic medications were limited to 14 days unless the resident's physician believed it was appropriate for PRN use and documented their rationale and can be renewed only after being evaluated by the attending physician, which affected one of 19 sampled residents, (Resident #4). As well as, the facility failed to ensure that one resident (Resident #23), had an appropriate diagnosis for psychotropic medication, and received a gradual dose reduction (GDR), and/or a rationale from the physician as to why the GDR was not attempted for one additional residents (Resident #73). The facility census was 94. The facility did not provide a policy regarding PRN use of psychotropic medications or Gradual Dose Reduction and Medication Review. 1. Review of Resident #4's annual Minimum Data Set, (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/22/22, showed: - Cognitive skills moderately impaired; - No…

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

Based on observations, interviews, and record review, the facility failed to ensure staff administered medications with a medication rate of less than 5%. Facility staff made two medication errors out of 31 opportunities for error, a medication error rate of 6.45%, which affected two of 19 sampled residents, (Resident #10 and #75). The facility census was 94. Review of the facility's policy for medication administration, dated 6/13/14, showed: - The right drug; - The right patient; - The right dose; - The right time; - The right route; - The right reason; - The right response; - The right documentation; - The right disbursement technique: each resident shall have their medication administered immediately after each individual's medication preparation. Review of the facility's policy for eye drops, dated 7/30/07, showed, in part: - Gently pull the lower eye lid down; - Drop the prescribed medication into the lower lid; - Instruct the resident to close his/her eye; - Gently press a tissue against the the lacrimal duct for approximately one minute; - If this cannot be accomplished then…

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

Based on observations, interviews, and record review, the facility failed to ensure staff discarded expired medications, and biologicals stored in the medication room on the 200 hall, failed to ensure the bottles of Morphine Sulfate (used to treat moderate to severe pain) were in containers that could be measured which affected four of 19 sampled residents, (Resident #9, #35, #87 and #90) and failed to discard expired Morphine Sulfate and Ativan (used to treat anxiety and seizure disorders) which affected two Residents, (Residents #9 and #35) and failed to ensure there were no loose pills in the day medication cart on the 200 and 500 hall. The facility census was 94. Review of the facility's policy for medication destruction, dated 7/30/07, showed: - Every medication that needs to be destroyed will be logged onto the drug destruction log; - This will consist of resident name, drug name, number destroyed, date of destruction, and the signatures of two licensed nurses witnessing the destruction; - The drug destruction log will remain on the wing for accessibility. Review of the…

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

Based on observation, record review and interview, the facility failed to maintain the kitchen in sanitary condition and ensure they stored food in a sanitary manner. The facility census was 95. Review of the facility policy titled Kitchenettes and Pantries, dated 2005, included the following: - Clean and sanitize refrigerator on a regular cleaning schedule, and as needed for spills. Review of the facility policy titled Cleaning Instructions Cleaning Refrigerators, dated 2005, included the following: - The refrigerators will be washed thoroughly inside and outside with a detergent and followed by a sanitizer at least once every month, or as needed. Spills and leaks will be wiped up as they are noticed. The facility did not provide a policy regarding dating food. Observation on 4/11/22 beginning at 10:13 A.M. showed the following: - The gas line behind the fryer was coated in sticky residue; - The following seasonings were open and did not have a date on them when they were opened: o 10 ounce (oz) Poultry Seasoning; o Two 16 oz containers of ground cumin; o 5.5 oz whole basil leaves;…

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

Based on record review and interviews the facility failed to maintain quarterly quality assessment committee (QAA) meetings with the required members. The facility census was 95. Record review of the facility's QAA meeting minutes, dated May 5, 2021. showed the following: -All the members met; -The members included the administrator, the director of nursing (DON), the Medical Director (MD), the Minimum Data Set (MDS) coordinator, business office manager, human resources, environmental service director and activities director. During an interview on 4/19/22 at 11:26 A.M. The Quality Assurance Nurse said: -The last QAA QAPI (Quality Assurance and Performance Improvement) meeting held was in May 2021. -He/she reviews the CASPER report quarterly . -He/she brings the CASPER report information to weekly Clinical meetings. -There are no sign in sheets for the weekly clinical meetings. -He/she is responsible for the QAA/QAPI meetings, but struggles getting all the mandated staff to attend. During an interview on 4/18/22 at 4:00 P.M. the Administrator said: -He/she thought there was a waiver…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public when when they failed to maintain their ceilings in good condition. The facility census was 95. 1. Observation and interview on 4/19/22 beginning at 12:45 P.M. showed the following: - room [ROOM NUMBER] had a gray substance all around the ceiling vent in the bathroom; - room [ROOM NUMBER] had a black substance all over the ceiling in the bathroom. The Maintenance Director said it looked like mold to him; - Unit 6 medication room had a baseball sized area on the ceiling that was yellow in color and flaking away from the ceiling. The Assistant Maintenance Director said he had not been in that room and did not know what the substance was. Observation 4/11/22 beginning at 11:00 A.M. showed the following areas had missing ceiling tiles: - #616 (several missing); - Corridor outside of room [ROOM NUMBER]; - #318 (two missing); - Four missing tiles in corridor…

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.