Pinnacle Point Wellness & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff provided care in a manner to prevent infection or the possibility of infection when staff failed to clean and disinfect a resident's mattress and seated rolling walker after being soiled with urine and feces, which affected one of the 23 sampled residents, (Resident #165), failed to use and failed to use personal protective equipment (PPE, equipment worn to minimize exposure to a variety of hazards, examples included gloves, gowns and masks) for residents who were on Isolation for Contact requirements or Enhanced Barrier Precautions (EBP, infection control measures that go beyond standard precautions and focus on reducing the transmission of multidrug-resistant organisms (MDROs), for Resident #1 and #103. The facility census was 112. Review of the facility's policy titled, Enhanced Barrier Precautions, dated 4/24 showed: - Enhanced Barrier Precautions are indicated for residents with infections or colonization with a Centers…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff treated residents in a manner to maintain their dignity when staff failed to knock on a resident's door and wait for a response before entering which affected four of 23 sampled residents, (Resident #1, #30, #104, and #165) and additionally when staff opened Resident #1's door exposing the resident's bare skin from the waist down, in view of the hallway. The facility also failed to shower one resident (Resident #32) per his/her preference. The facility census was 112. Review of the facility's policy titled, Resident [NAME] of Rights, revised 1/23, showed: - Each resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life, regardless of diagnosis, severity of condition or payment source and to exercise those rights as a citizen 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 ensure accurate and timely update of assessments when one resident's (Resident #48) change in functional abilities and use of a wheelchair, was not updated with a significant change and when one resident (Resident #86) had a change in cognitive status from cognition intact to cognition severely impaired on the Minimum Data Set (MDS) ( a federally mandated assessment completed by facility staff). This occurred for two of twenty-three sampled residents (Resident #48 and #86). The facility census was 112. The facility did not provide a policy regarding updating the MDS when residents have a change of condition. 1. Review of Resident #48's, Significant change MDS, dated [DATE], showed: -Cognition severely impaired. -Hospice care added, which was not on prior MDS; -He/She was dependent on a walker; -He/She required set up or clean up assistance with eating only; -He/She required partial to moderate assistance with toileting, bathing, dressing,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff developed and updated a care plan consistent with resident's specific conditions and needs (Resident #74), resident's shaving preferences (Resident #25), and resident's change in mobility status and need for feeding assistance (Resident #48) which affected three (Resident #74, #25, and #48) of 23 sampled residents. The facility census was 112. Review of facility policy, comprehensive person-centered care plans, dated 1/2025, showed: -Each resident would have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that would identify how the interdisciplinary team would provide care. -Care plan could be revised at quarterly intervals in conjunction with the completion of MDS quarterly, significant change, and annual assessments per the RAI manual; -The Interdisciplinary team along with resident and or resident's representative will identify resident problems, needs, strengths, life…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility staff failed to ensure residents remained free from accident hazards when staff pushed residents in their wheelchairs without foot pedals in place for three residents (Resident #29, #83, and #79) of the 23 samples residents. The facility census was 112. Review of the facility policy, Resident [NAME] of Rights, dated January 2023, showed the facility shall provide a safe environment. Facility did not provide a policy on regarding accident prevention. Review of facility policy, Accident and incident documentation and investigation, dated July 2018, showed: -Accidents and/or incidents involving resident care will be investigated and documented on there resident incident report entry form in the long term care system. An incident is defined as an occurrence which is not consistent with routine operation of the facility or the routine care of a particular resident. Accidents and incidents will be analyzed for trends or patterns to enable the facility to…

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

Based on observation, interview, and record review, the facility failed to ensure staff administered medications with an error rate of less than five percent (5%). Staff made two errors out of 25 opportunities for error, which resulted in an error rate of 8%. This affected one of the 23 sampled residents, (Resident #72). The facility census was 112. Review of the facility's policy titled, Medication administration-general guidelines, revised 8/16, showed: - Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so; - Personnel authorized to administer medications do so only after they have familiarized themselves with the medication; - Prior to administration, the medication and dosage schedule on the resident's medication administration record (MAR)/eMAR (electronic MAR) is compared with the medication label; - Information on the medication should be checked against the MAR/eMAR or treatment administration record (TAR)/electronic TAR (eTAR) at least three times during the med preparation 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 store medications in a locked storage area to ensure medications were inaccessible to unauthorized staff and residents, when eye drops (Resident #26) and one blue pill (Resident #27) were left at bedside. This affected two out of 23 sampled residents. The facility census was 112. Review of facility policy, Medication Administration General Guidelines, revised August 2016, showed: - Residents are allowed to self-administer medications when specifically authorized by the attending physician and the interdisciplinary team and in accordance with procedures for self-administration of medications; - In the event a non-controlled medication is refused by the resident, the nurse is to waste the medication by placing it in the sharps container or a clearly labeled container or cabinet in a locked secured area designated for that purpose until destroyed; Review of facility policy, Medication Administration General Guidelines, revised August 2016,…

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 acceptable accommodations for one non English speaking resident (Resident #104) and failed to provide one resident appropriate seating for meal times when his/her chair put his/her at face at table height (Resident # 26). This affected two of 21 sampled residents. The facility census was 103. Facility did not provide a policy on accommodation of needs. Review of Resident [NAME] of Rights, revised 1/23, showed: -Each resident had a right to dignified existence, self-determination, and communication with and access to persons and services and outside the facility in a manner and in an environment that promotes maintenance or enhancement of (his or her) quality of life, regardless of diagnosis, severity of condition. -Informed in a language he/she can understand of his/her total health status, including but not limited to, his/her medical condition. -Reside and receive services in the facility with reasonable accommodation of residents needs and preferences except when to do so would endanger the health…

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

Based on interview and record review, the facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) form CMS - 10123, to Medicare beneficiaries at least two days before the end of a Medicare covered Part A stay. This affected two out of 21 sampled residents (Resident #1 and #93). The facility census was 103. The facility did not provide the requested policy for Notice of Medicare Non-Coverage (NOMNC) form CMS - 10123. CMS Guidlines: Form CMS-10123, is given by the facility to all Medicare beneficiaries at least two days before the end of a Medicare covered Part A stay or when all of Part B therapies are ending. The NOMNC informs the beneficiaries of the right to an expedited review by a Quality Improvement Organization. 1. Review of Resident #1's medical record showed: -The resident had a Notice of Medicare Non-Coverage (NOMNC) issued that showed Medicare Part A benefits were ending on 8/20/24; -The NOMNC was signed by the resident on 8/20/24; -The resident's record showed the facilty failed to ensure the resident received the NOMNC at least at least two days before 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 4. Review of Resident #77's Quarterly Minimum Data Set (MDS), completed by facility staff and dated 8/9/24, showed: - Cognitive skills intact; - Independent with transfers; - Diagnoses included anxiety and depression. Review of the resident care plan, dated 4/4/2022, showed: - The resident had an alteration in sleep pattern related to insomnia ( persistent problems falling and staying asleep); administer medications as ordered by the physician; observe for changes in sleep pattern inability to fall/stay asleep; provide a quiet restful environment. During an interview on 10/7/24 at 3:17 P.M., the resident said; - The staff take the smoking cart outside and roll it past his/her door and it is very loud; - There is something broken on it and it makes a loud clunking sound; - The smoking cart has been broken for over a month; - He/she has trouble sleeping at night and it has woken him/her up before. Observation on 10/8/24 at 7:14 A.M., showed: - Staff pushing the smoking cart down the hallway to the exit for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents were free from physical restraints when the facility failed to obtain a physician's order, assess, monitor or care plan the use of a seat belt (a belt or strap used to secure a person to prevent injury) for one resident (Resident #11) and when the facility staff failed to unlock the wheels of a wheelchair for one resident (Resident #84) after the resident was observed pushing against the table with his/her hands, pushing back into the back of the wheelchair and yelling out repeatedly, He/She didn't want it. The facility census was 103. Review of the facility's Restraint Evaluation and Reduction policy, dated December 2023, showed in part: -All residents have the right to be free from restraints; -Physical restraints are identified as any manual method or physical devise attached to the resident's body that they cannot remove easily and restricts freedom of movement; -The following devices are considered a restraint and…

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

Based on record review and interview, the facility failed to check the Family Care Safety Registry (FCSR, a registry that provides background information on people who work with children, seniors, and people with disabilities in Missouri) for three of the 10 sampled employees prior to them having contact with any resident. The facility census was 103. Review of the facilty's Abuse Prevention Policy, dated October 2022, showed in part: -The facilty is committed to protecting the residents from abuse; -The facilty conducts employee back ground checks; -The facilty will pre -screen all potential employees for a history of abusive behavior. 1. Review of Dietary Aide E's personnel file showed: -Date of hire 9/17/24; -A check of the FCSR dated 10/9/24; -The facilty failed to check the FCSR before the employee had contact with the residents. 2. Review of Licensed Practical Nurse (LPN) H's personnel file showed: -Date of hire 5/8/24; -A check of the FCSR dated 5/20/24; -The facilty failed to check the FCSR before the employee had contact with the residents. 3. Review of Certified Nurses…

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 assure resident Minimum Data Set (MDS: a federally mandated Assessment tool completed by facility staff) assessments were completed accurately and timely for four of 21 sampled residents (Residents #72, #33, #84 and #39). The census was 103. Review of the facility provided policy, MDS Assessments dated 6/2023 showed: -The facility shall conduct interdisciplinary assessments using the MDS item sets. These assessments provide information on the resident's condition to facilitate development of an individualized plan of care as a means by which the facility can track changes in a resident's status. -Non-Medicare covered residents will be completed upon admission, discharge, quarterly and annually per Federal/State requirements. -Death in facility and entry tracking records will be completed per the Resident Assessment Instrument (RAI) instructions. 1. Review of Resident #72 Electronic Health Record showed: -admission date of 2/3/24;…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to develop and implement a comprehensive person-centered care plan for four of 21 sampled residents (Residents #39, #113, #26, #84) by not addressing care areas of resident side rail usage (Resident #39 and #113), use of a bilevel positive airway pressure device (bipap) (a noninvasive ventilator that helps people breathe by delivering pressurized air into airways) (Resident #39), and significant weight loss (Resident #26 and #84). The facility census was 103. Review of facility policy, comprehensive person centered care plans, revised March 2018, showed: -Each resident will have a person centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care; -The interdisciplinary team along with the resident and/or resident representative will identify resident problems, needs, strengths, life history, preferences, and goals; -For each problem, need, 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 observations, interviews and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADL's) received the necessary services to maintain good personal hygiene when staff failed to ensure they provided perineal care at least every two hours. This affected two of the 21 sampled residents, (Resident #11 and #19). The facility census was 103. Review of the Missouri Resident [NAME] of Rights, provided through the state long term are ombudsman (a person who represents the interests of residents) program included Residents have the right to privacy, to be treated with consideration, respect, and dignity, recognizing each resident' s individuality. Review of the facility's Incontinent Care Policy, review date January 2015, showed -Provide routine, preventative skin, perineal care after each incontinent episode. 1. Review of Resident #11's, Quarterly Minimum Data Set (MDS, a federally mandated assessment tool completed by facility staff), dated…

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 treat significant weight loss for two residents (Resident #26 and #84) and failed to provide adequate hydration for 6 residents (Resident #26, #84, #35, #57, #94 and #4) of the 21 sampled residents. The facility census was 103. Review of the facility provided policy Hydration Cart dated 2016 showed: -Water or other fluids shall be offered to all residents throughout the day. Fluids are typically offered during meals, snacks. A hydration cart or location may be used to enhance access and encouragement of fluids for residents. -The Hydration Cart will be offered or refreshed each day at mid morning, mid afternoon and bedtime. -The cart or location will include fresh ice water and another beverage such as iced tea or lemonade. And may include snacks. -The cart or location will include fluids appropriate for those on thickened liquids. The facility did not provide a policy on weight loss or meal intake. 1. Review of Resident #26's Quarterly…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility staff failed to assess residents for risk of entrapment from bed rails prior to installation and failed to ensure the bed's dimensions were appropriate for the resident's size and weight, and failed to obtain physician's orders for side rails for four of 21 sampled residents (Resident #39, #113, #54, and #104). The facility census was 103. The facility did not provide a policy on entrapment. 1. Review of Resident #39's quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 9/13/24, showed: -He/She was cognitively intact; -He/She had clear speech, was able to make self-understood and understand others; -He/She was dependent on his/her wheelchair for mobility; -He/She required partial/moderate assistance from staff with dressing, toileting, bathing, and mobility from sitting to lying; -Diagnoses included respiratory failure (condition when lungs can not get enough oxygen into blood or remove enough…

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 error rate of less than 5%. Facility staff made five medication errors out of 26 opportunities for error, resulting in a medication error rate of 20%. This affected five of the 21 sampled residents, (Resident #4, #15, #43, #91 and #103). The facility census was 103. Review of the facility's policy for general guidelines for medication administration, dated 8/16, showed, in part: - Medications are administered as prescribed, in accordance with good nursing principles and practices and only be persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication; - Medications are administered in accordance with written orders of attending physicians, taking into consideration manufacturer's specifications and professional standards of practice; - Medications are administered within the identified block of time per facility defined parameters. One hour before and one hour…

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 provide food that was palatable and attractive when hall trays were not served per resident food preferences and was not attractive. The deficient practice affected two of 21 sampled residents (Resident #85 and #52 ). The facility census was 103. The facility did not provide a policy for resident food preferences. 1. Review of Resident #85's Quarterly MDS, dated [DATE], showed: -He/She had severe cognitive impairment; -He/She required set up or clean up assistance with eating; -Diagnoses included: cancerous tumor, dementia, and anxiety. Review of care plan, undated, showed: -He/She was able to feed self but had dementia that may affect food intake and his/her weight; -Obtain/update food preferences; -Serve diet as ordered. Review of physician's orders, dated October 2024, showed: -Ordered 6/10/24, He/She was on a regular diet. During an observation on 10/9/24 at 1:10 P.M., showed: -Resident's rice was in form of ice cream scoop; -Resident observed having…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure the walls, ceilings, and floors, of the facility were maintained in good repair. This had the potential to affect all residents. The census was 103. The facility did not provide a policy on upkeep and repair. 1. Observations beginning on 10/08/24 at 7:58 A.M. on the Special Care Unit (SCU) showed: -Hallway light fixtures had dead bugs, dust and debris; -Hallway hand rails were scratched and had scuff marks; -The Utility room door had large scratches and chipped paint; -room [ROOM NUMBER] entry door was scratched with large areas of chipped paint and drug against the floor when opening/closing; -room [ROOM NUMBER] entry door had chipped paint that exposed the wood underneath; -room [ROOM NUMBER] entry door was scratched with chipped paint; -room [ROOM NUMBER] entry door had multiple paint chips that exposed the wood underneath; -The Dining/Activity room baseboard had thick black/gray, crusty debris at edge of baseboard and floor;…

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 maintain an effective pest control program to prevent gnats, flies and wasps in resident rooms, dining rooms, and hallways. The facility census was 103. The facility did not provide a pest control policy. 1. Observation on 10/07/24 at 9:18 AM showed multiple gnats in room [ROOM NUMBER]. 2. Observation on 10/07/24 at 11:05 A.M. showed multiple flies in the dining room. 3. Observation on 10/07/24 11:21 AM showed room [ROOM NUMBER]: -A fly strip hanging from the room divider with multiple dead flies on it; -Multiple flies and gnats in the room. 4. Observation on 10/07/24 at 11:30 AM Resident #18 said -There were flies in his/her room a lot; -There were multiple flies in room, landing on resident and crawling on the bed. 5. Observation on 10/08/24 at 7:58 A.M. on the Special Care Unit showed: -Two large wasps on the nursery room wall; -room [ROOM NUMBER] had multiple flies in the room, crawling on the resident, the bed and flying throughout…

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

Based on observation, interview and record review, the facility failed to ensure residents were cared for in a dignified way when staff tugged on a residents shirt, ignoring the residents repeated requests for them to stop. Furthermore, staff treated the resident disrespectfully by yelling at the resident when the resident attempted to self propel his/her wheelchair up and down the halls of a secured care unit. This affected one of 21 sampled residents (Resident #85). The facility census was 103 Review of the facility provided Resident [NAME] of Rights dated 01/2023 showed: -Each resident has a right to a dignified existence, in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life -The right to self determination, which the facility must promote and facilitate through support of resident choices about aspects of of his/her life in the facility. Including but not limited to activities, health care schedules and how he/she spends time. -The right to be free of abuse, neglect, exploitation, misappropriation Review of Resident #85's…

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

Based on interviews and record review, the facility failed to assist one resident of the 21 sampled residents (Resident #82) with help in obtaining a hearing aide. The facility census was 103. Review of the facility's job description for the director of social services, dated 8/1/2012, showed, in part: - Under the direction of the Executive Director, the Social Services Director is responsible for monitoring the residents' mental and psycho-social needs and to provide the services to meet these needs in order to attain or maintain the highest practicable level of physical, mental, and psycho-social well-being; - Utilizes the Resident Assessment Instrument (RAI) process in conducting a psycho-social assessment; - Formulates a care plan which addresses the identified problems, needs, and concerns; - Documents progress toward goals, assessment updates, and interventions; - Reviews the resident's progress toward resolution of problems, needs, or concerns,; evaluates the effectiveness of the staff approaches, evaluates changes in the mental and psycho-social assessment; - Participates in…

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

Based on observations, interviews, and record review, the facility failed to ensure staff provided a safe and effective medication administration system that was free of significant medication errors when staff failed to provide a meal to a resident within 15 minutes after receiving fast acting insulin. This affected one out of 21 sampled residents, (Resident #103). The facility census was 103. Review of the facility's policy for general guidelines for medication administration, dated 8/16, showed, in part: - Medications are administered as prescribed, in accordance with good nursing principles and practices and only be persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication; - Medications are administered in accordance with written orders of attending physicians, taking into consideration manufacturer's specifications and professional standards of practice; - Medications are administered within the identified block of time per facility defined parameters. One hour before and one hour…

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, and staff interview, the facility failed to ensure prescribed medications were administered at the prescribed time and were available for administration for eight of 13 residents (Resident (R)95, R62, R24, R41, R54, R263, R17, and R48) in the medication administration observation. These failures caused 29 medication errors out of 59 opportunities for error, or a medication error rate of 49.15%. The facility census was 115. Findings include: Review of the facility policy Medication Administration-General Guidelines dated 08/16, revealed . Medications are administered in accordance with written orders of attending physicians . All current medications and dosage schedules are listed on the resident's medication administration record .and administered timely according to facility policy . Medications are administered within the identified block of time per facility defined parameters. One hour before and one hour after the scheduled time, except for orders relating to before,…

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 maintain a qualified administrator on duty from 2/15/2024 to 3/3/2024. The facility census was 106. During an interview on 2/14/24 at approximately 4:00 P. M., Administrator B notified the state survey agency that he/she was no longer the Administrator of record at the facility. Review of the current Missouri Board of Nursing Home Administrators (MBNHA) license registry website showed Administrator A not listed as a current Missouri Licensed Administrator. During an interview on 2/27/2024 at 11:50 A.M., Administrator A said: -He/She had completed the Administrator in Training program, but has not taken the test to obtain an administrator license. -He/She thought the State regulations state the new administrator had 120 days to obtain an administrator license. -He/She was unsure if anyone at the corporate level was a licensed administrator in Missouri and would act as a licensed administrator until he/she obtained a license. During an interview on 2/28/2024 at 9:53 A.M., Corporate [NAME] President A said: -Administrator A'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 This deficiency is uncorrected. For previous examples, see the Statement of Deficiencies dated 11/20/23. Based on observation, interview, and record review, the facility failed to ensure four (Resident #21, #57, #80, #7) of six sampled residents who required staff assistance received the necessary assistance with bathing. The facility census was 109. Review of facility policy, Bath/Shower-Dependent, dated 9/03, showed a bath for cleanliness and comfort is scheduled at least weekly for each resident. 1. Review of Resident #21's Annual Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 10/5/23, showed: - A Brief Interview Mental Status (BIMS) an assessment used in long term care facilities to monitor cognition) of 15, which indicated he/she had intact cognition; - He/She was dependent of staff help for toileting hygiene, bathing, upper body dressing, lower body dressing, putting on footwear, rolling left to right, sitting to lying, lying to sitting, and all transfers; -…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure the call light system was accessible and functioned properly for two of 22 sampled residents who required staff assistance (Resident #19 and #57). The facility census was 106. The facility did not provide a policy regarding call lights. 1. Review of Resident #57's quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 8/31/23, showed: - No Brief Interview of Mental Status (BIMS); - No recorded resident preferences; - Substantial/Maximal assistance for toileting hygiene, showering upper and lower body dressing, rolling left and right, and sitting to lying; - The resident was always incontinent of bowel and bladder; - Diagnoses of Hypertension (HTN), heart failure, diabetes, severe obesity, and a burn of second degree to the abdominal wall. Review of the resident's Comprehensive Care Plan, dated 11/8/23, showed: - He/She was at risk for skin break down related to needing assistance…

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.