Windsor Estates Of St Charles

Based on interview and record review, the facility failed to ensure the Dietary Manager (DM) had the appropriate competencies and skills set to carry out the function of the food and nutrition services. This practice effected all residents in a facility. The facility census was 62. The facility did not have a policy regarding training or competency requirements for the Dietary Manager. 1. Review of the Food Establishment Inspection Report from the local county health department dated 2/12/25 showed: -Foodborne Illness Risk Factors and Public Health Interventions: Supervision: Certified Food Protection Manager out of compliance; -2-102 in accordance with Section 2-102-11, the person in charge must successfully complete a program that is approved by the Department for food protection manager certification and have posted in the food establishment a current certificated of training issued by the program; During an interview on 5/1/25 at 10:30 A.M. the DM said the following: -He had been the dietary manager for a couple of years; -He was enrolled in an online dietary manager course with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to properly label food for expiration date, failed to discard food that has passed the expiration date as identified on the food label, failed to maintain one refrigerator to be free of rust and ice build up and failed to ensure a thermometer was present in the refrigerator. The facility failed to label and date when a food item was opened and refrigerated. The facility census was 62. Review of the undated facility policy for Food storage (Dry, Refrigerated, and Frozen) showed the following: -Food shall be stored on shelves in a clean, dry area, free from contaminants. Food shall be stored at appropriate temperatures using appropriate methods to ensure the highest level of food safety; -All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discharged ; -Discard food that has passed the expiration date; -Keep potentially hazardous foods out of the temperature danger…

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 facility staff provided four residents (Resident #2, #6, #10 and #11), who were unable to perform their own activities of daily living, the necessary care and services to maintain good personal hygiene and prevent body odor, in a review of 11 sampled residents. The facility census was 61. Review of the facility's undated policy, Activities of Daily Living, showed the following: -The facility provides each resident with care, treatment and services according to the resident's individualized care plan; -Based on the individual resident's comprehensive assessment, facility staff will ensure that each resident's abilities in activities of daily living do not diminish unless circumstances of the resident's clinical condition demonstrate that the decline was unavoidable, including bathing and grooming. Upon request, the facility responded they did not have a policy for showers, shaving, nail care or haircuts. 1. Review of the Resident…

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

Based on observation, interview and record review, the facility failed to maintain the water supply to the dishwasher in good working condition. The water pipe to the dishwasher leaked, causing water to pool under the dishwasher and run onto the floor in the dishwashing area. The facility census was 62. 1. Review of an inspection report dated 2/12/25 from the local county public health department showed: -Leaking plumbing or plumbing in disrepair; -Out of compliance with plumbing. Observation on 5/1/25 between 9:50 A.M. to 2:30 P.M. and again on 5/2/25 between 6:30 A.M. to 12:30 P.M. showed the following: -Water dripped out of pipes located under the dishwashing machine in the kitchen; -Pooled water under the dishwasher and the shelving attached to the dishwasher that flowed out from under the dishwasher and onto the floor. During an interview on 5/2/25 at 11:15 A.M. [NAME] C said the following: -The dishwasher had been leaking for over a year; -The kitchen staff mop up the water several times a day. During an interview on 5/1/25 at 10:20 A.M. the Dietary Manager said the following:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents received care and services in accordance with professional standards of practice when staff failed to ensure ordered medications were available for administration for two residents (Resident #1 and Resident #2), in a review of four sampled residents. The facility census was 61. 1. Review of Resident #1's face sheet showed the resident admitted to the facility on [DATE] with diagnoses of infection of a joint prosthesis and low back pain. Review of the resident's physician orders dated 2/18/25 showed an order for Tramadol (medication used to relieve moderate to moderately severe pain, including pain after surgery) 50 milligrams (mg) every six hours as needed (PRN) for pain. Review of the resident's nurses note dated 2/19/25 at 6:03 P.M., showed staff notified the physician about the resident complaints of lower back pain, that Tramadol had not been delivered at this time and the physician needed to sign a script 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 maintain a call system that was adequately equipped to to ensure staff received alerts through a communication system which relayed the call directly to a staff member or to a centralized staff work area with an audible sound. This affected the entire facility. The facility census was 66. 1. Review of the facility's daily census sheet provided by the facility on 2/21/25 showed the following: -100 hall with 19 residents; -200 hall with 29 residents; -300 hall with 18 residents. 2. Review of Resident #1's comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 12/19/24 showed the following: -Able to make self understood and able to understand others; -Alert and oriented and able to make decision; -Requires supervision with transfers from bed to chair or toilet and from chair or toilet to bed. Observation on 2/21/25 at 11:03 A.M. showed the resident lay in bed with a call light cord next 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop an admission policy and implement an admission protocol to ensure residents and/or residents' representatives signed the admission agreement for one resident (Resident #10). The facility also failed to ensure at least a 30 day notice was provided to four residents (Resident #2, #5, #6, and #11) and/or the resident representatives in writing for an increase in charges for services provided to residents at the facility. The facility census was 59. During an interview on 7/22/24 at 2:45 P.M. the administrator said the facility did not have an admission policy. Review of the facility's Financial Responsibility Agreement, private method of payment section, dated October 2015, showed the following: -The agreement is for payment for the care and services that are provided to the resident by the facility; -The facility will provide the resident and his/her authorized representative with not less than 30 days prior written notice of any increase 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 interviews and record review, the facility failed to employee a Food Service Director (FSD) with credentials that were not expired. This failure had the potential to affect 55 of 55 residents as there were no enteral feeding residents at the facility. Findings include: Interview on 03/20/24 at 8:05 AM the Director of Nursing (DON) stated the facility has a Registered Dietician (RD) who was at the facility two days a week. The DON stated that the FSD does not have a certification at this time. The DON stated the FSD started in October of 2023 and the Administrator (ADM)2 was going to pay and enroll the FSD in the certification course, however, this did not occur. Interview on 03/20/24 at 11:35 AM, the FSD confirmed that he started October 2023 and that he has started the certification course but has not completed it. Interview on 03/21/24 at 11:25 AM, the Regional Director of Operations (RDO) stated the FSD did not have his certification for food and safety management. Review of facility's job description titled, 6001 Dietary Supervisor Position Description supplied 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review, and policy review, the facility failed to ensure a resident that had nasal medication and two inhaler medications on the resident's bedside had a self-administration of medication assessment, a physician's order, and care plan completed for one of one resident (Resident (R) 3) reviewed for self-administration of medications. Failure to assess and care plan residents for self-administration of medications increases the potential of medication errors for residents. Findings include: Review of facility's policy titled, Self-Administration of Medications by Residents, dated 05/19, revealed Self-administration medications will be encouraged if it is desired by the resident, safe for the resident and other residents of the facility, ordered by the attending physician, and approved by the Interdisciplinary team (IDT). Procedure: 1. Each resident is offered the opportunity to self-administer his or her medications during the routine assessment by the facility IDT. 2. If…

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 record review, interview and policy review, the facility failed to ensure an allegation of injury of unknown origin was reported to the State of Missouri Department of Health and Senior Services State Agency (SA) timely for one or one (Resident (R) 21) reviewed for abuse in the sample of 19. Findings include: Review of R21's admission Record, located in the Profile tab of the electronic medical record (EMR) revealed admission to the facility on [DATE] and readmission was on 03/18/24 with diagnoses of Alzheimer's disease, cerebral infarction, and repeated falls. Review of R21's quarterly Minimum Data Set (MDS) under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 12/26/23, revealed the Brief Interview for Mental Status (BIMS), was unable to be completed due to the resident was rarely understood. Review of the facility's Reportable Event revealed that R21's injury of unknown origin was found on 03/12/24 at 8:49 AM. However, the incident was not reported until 03/18/24 at 3:11 PM. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and policy review, the facility failed to ensure an investigation was immediately initiated when an allegation of injury of unknown origin was found for one of one resident (Resident (R) 21) reviewed for abuse in the sample of 19. Findings include: Review of R21's admission Record, located in the Profile tab of the electronic medical record (EMR) revealed admission to the facility on [DATE] and readmission was on 03/18/24 with diagnoses of Alzheimer's disease, cerebral infarction, and repeated falls. Review of R21's quarterly Minimum Data Set (MDS) under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 12/26/23, revealed the Brief Interview for Mental Status (BIMS), was unable to be completed due to resident was rarely understood. Review of the facility's Reportable Event revealed R21's injury of unknown origin was found on 03/12/24 at 8:49 AM. However, the investigation was not initiated until 03/18/24. Review of a Nurse's Note, in the EMR, under the Notes tab…

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 record review, and interview, the facility failed to update the resident's care plan with new interventions for one of three residents (R )21) care plans reviewed in the sample of 19. Specifically, R21, who had wandering behaviors, left the skilled nursing unit without staff knowledge or supervision and was found in the portion of the building identified as the independent living Bistro on 09/03/23 and then again found missing for over two hours on 10/05/23 in the portion of the building identified as the chapel which was located past two closed double doors at the end of the hall. Findings include: Review of R21's admission Record, located in the Profile tab of the electronic medical record (EMR) revealed admission to the facility on [DATE] and readmission was on 03/18/24 with diagnoses of Alzheimer's disease, cerebral infarction, and repeated falls. Review of R21's quarterly Minimum Data Set (MDS) under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 12/26/23, revealed the Brief…

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, interview and policy review, the facility failed to prevent a resident with wandering behaviors from leaving the skilled nursing unit without staff's knowledge or supervision for one of three residents (R )21) reviewed for accidents in the sample of 19. Specifically, R21 left the skilled nursing unit and was found in the portion of the building identified as the independent living Bistro on 09/03/23 and then again found missing for over two hours on 10/05/23 in the portion of the building identified as the chapel which was located past two closed double doors at the end of the hall. Findings include: Review of R21's admission Record, located in the Profile tab of the electronic medical record (EMR) revealed admission to the facility on [DATE] and readmission was on 03/18/24 with diagnoses of Alzheimer's disease, cerebral infarction, and repeated falls. Review of R21's quarterly Minimum Data Set (MDS) under 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 observation, interviews, record review, and facility policy review, the facility failed to ensure that the Certified Nurse Aide (CNA)changed gloves and performed hand hygiene when going from a contaminated area to a clean area for one of one resident (Resident (R) 18) observed for catheter care from a total of 18 residents sampled, to prevent possible cross contamination. Findings include: Review of the facility's policy titled, Prevention of Catheter-Associated Urinary Tract Infections, dated 2019, revealed .Standard Precautions .2. Hand hygiene is performed immediately after any manipulation of or contact with the catheter site, catheter, tubing, drainage bag, or emptying container, even when gloves were worn. Review of facility policy titled, Standard Precautions, dated 2019, revealed Gloves . Policy .3. Sterile gloves and examination gloves are removed .d. before touching uncontaminated surfaces or other areas of the same resident's body that may be uncontaminated. Review of R18's (facility…

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 provided one resident (Resident #1 and #2 ), who were unable to perform own activities of daily living (ADLs), in a review of 5 sampled residents, the necessary care and services to maintain good personal hygiene. The facility census was 57. The facility did not provide a policy for Peri Care for the gender specific resident. Review of the undated Skills Checklist for Peri Care ( a tool used to train staff on how to properly provide peri care showed the following: -Apply gloves; -Help the resident into a dorsal recumbent (lying on the back with the knees slightly bent) position; -Wash and dry upper thighs; -Separate the perineal folds and wash in a down stroke alternating from side to side moving outward on the thighs; -Use a different wash cloth for each stroke; -With fresh water and a clean washcloth, rinse area thoroughly with same strokes; -Gently pat dry; -Position the resident on the side exposing buttocks; -Clean rectal…

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 nursing staff washed their hands and changed gloves appropriately while performing peri care for two residents (Resident #1 and #2), of five sampled residents. The facility census was 57. Review of the undated facility policy for Hand Hygiene showed the following: -Appropriate hand hygiene is essential in preventing transmission of infectious agents; -Hand hygiene continues to be the primary means of preventing the transmission of infection. Hand hygiene (washing hands and or Alcohol-Based Hand Rub (ABHR) are consistent with accepted standards of practice such as the use of ABHR instead of soap and water in all clinical situations except when hands are visibly soiled (e.g. blood, body fluids) or after caring for a resident with a known or suspected Clostridium (C.) difficle (an infection affecting the gut) or norovirus (an infection affecting the gastro intestinal tract) infection during an outbreak; if exposure to Bacillius…

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

Based on interview and record review, the facility failed to follow physician orders for one resident (Resident #2) of two sampled residents, when staff failed to notify the physician and obtain orders for blood work and an x-ray that were recommended from an outside wound care provider. The facility census was 59. The facility did not provide a policy for following physician orders or policy for notifying the physician of recommendations from an outside wound care provider. 1. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 9/15/23 showed: -The resident was unable to understand or make self understood; -Was not oriented to person, place or time; -Totally dependent upon two staff members for Activities of Daily Living (ADL's); -Diagnoses of stroke, diabetes, and Crohn's disease (an inflammatory bowel disease that causes chronic inflammation of the GI tract, which extends from the stomach all the way down to the anus). Review of the outside wound care provider's note dated 9/29/23 showed: -Labs orders 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 one resident (Resident #2), of two sampled residents, received care and services to prevent weight loss. Staff failed to obtain weights per facility protocol. As a result, the facility failed to identify the resident's weight loss and failed to notify the physician and dietitian of the weight loss to address the weight loss. The resident had a weight loss of 5.3 pounds in 23 days for a 6.81% weight loss (considered severe loss). The facility census was 59. Review of the facility policy for Weight Assessment and Interventions dated 1/2017 showed: -Weight Assessment: Nursing staff will measure the resident's weights on admission, and weekly for four weeks thereafter If no weight concerns are noted at this point, weights will be measured monthly; -Weights will be recorded in the individual's medical record; -The threshold for significant unplanned and undesired weight loss will be based on the following criteria: one month - 5% weight…

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 followed appropriate infection control procedures when staff failed to change gloves after performing an accucheck procedure (finger stick to obtain blood), for one resident (Resident #32) in a review of 20 sampled residents. Staff handled multiple residents' insulin pens with contaminated gloves and gave insulin with contaminated gloves. The facility also failed to keep one resident's (Resident #9)'s ,urine collection bag off the floor to reduce risk of infection. Further review showed the facility failed to implement their water management program to identify and reduce the risk of Legionella bacteria (cause of Legionnaire's disease - a severe form of pneumonia) growth and spread. The facility census was 54. Review of a facility policy titled, Blood Sampling - Capillary (Finger Sticks), reviewed February 2021, showed the following: -Steps in the Procedure: 1. Wash hands. Explain procedure to resident. 2. [NAME] gloves. 3. Place blood glucose monitoring device on clean field. 4. Place a new…

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 one resident (Resident #10) had a call light or other means of summoning staff when needed, and failed to ensure two residents (Resident #1, 21), who were dependent on staff for activities of daily living, consistently had access to a call light or other means of summoning staff within reach of the residents, in a sample of 20 residents. The census was 53. During an interview on 7/7/22 at 4:36 P.M., the interim administrator said the facility did not have a policy regarding call lights. 1. Review of Resident #20's care plan, dated 1/25/22, showed the resident was totally dependent on staff with his/her activities of daily living (ADLs) and mobility with cerebrovascular accident (stroke) with dysphagia (difficulty or discomfort in swallowing, as a symptom of disease) and left hemiplegia (paralysis of one side of the body). Observation on 7/5/22 at 11:35 A.M., showed the resident lay in bed. The resident's call light was on 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 provide housekeeping and maintenance services necessary to ensure the environment was clean and maintained in good repair. The facility census was 54. Observation on 7/5/22 at 11:18 A.M. in resident room [ROOM NUMBER], showed the following: -Two wood sliding closet doors would not open or close properly. Both sliding closet doors were marred and scratched; -The flooring in the room was covered with numerous white areas of dried debris; -The drywall was marred and the cove base was peeled back at the base of the wall by the bathroom. Observation on 7/5/22 at 9:56 A.M., 11:22 A.M., and 1:48 P.M. in resident room [ROOM NUMBER], showed the following: -The flooring in the room was covered with a heavy buildup of crusty dried debris; -The drywall was marred and missing paint; -White flakes of paint were located on the floor next to the bathroom and on the bathroom floor; -A large stain approximately 1 foot by 2 feet on the bathroom 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 observation, interview and record review, the facility failed to ensure residents knew how they could file a grievance other than through resident council, failed to ensure the facility responded to all grievances and made prompt efforts to resolve any grievances. Residents said they felt their concerns were not heard or addressed. The facility did not follow their policy with the administrator signing, reviewing and documenting the completion of the grievance process. The facility census was 54. Review of the facility policy, titled Resident Grievance Policy and Procedures, revised February 2021, showed the following: -It is the intent of this facility/community to encourage residents, their representatives or family members, opportunities to communicate any concerns, suggestions, complaints or opportunities for improvement in care or services. This facility/community offers a variety of mechanisms to communicate this information. One of these is the Grievance Process; -POLICY: Utilization 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 interview and record review, the facility failed to ensure one resident (Resident #805), in a review of 20 sampled residents, was free from misappropriation of property, when the former Director of Nursing (DON) misappropriated the resident's narcotics. The former DON had pulled the resident's narcotic medication from the active medication cart, stating the medication had been discontinued when there was no documentation to support the medication had been discontinued. Further review showed the former DON improperly prepared the medication for destruction and upon investigation, there was one less tablet accounted for than was on the narcotic control sheet. The facility census was 54. Review of the undated pharmacy Controlled Substance Storage and Handling policy showed the following: -Policy: Controlled substances (medications in Schedule II, III, IV, V) have high abuse potential and may be subject to handling, storage and record keeping; -Procedure: -E: 3) Schedule II medications and any other medications that the facility requires a more stringent control, will be kept…

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

Based on interview and record review, the facility failed to ensure a Quarterly Minimum Data Set (MDS), a federally mandated resident assessment completed by the facility staff, was completed no less than once every three months for two of 20 sampled residents (Resident #5 and #6). The facility census was 54. Review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual MDS 3.0, dated 2019, showed the following: -The OBRA of 1987 provided the statutory authority for federal statute and regulations that required nursing homes to conduct initial and periodic assessments for all their residents. The assessment information is used to develop, review, and revise the resident's plans of care that will be used to provide services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; -The Quarterly Assessment is a non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type; -It is used…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow standards of practice and physician orders for four residents (Residents #21, #28, #32 and #42) in a review of 20 sampled residents, and for one additional resident (Residents #5). Staff did not follow physician orders, did not prepare or administer medications as ordered, did not ensure medications were available for administration, administered medications when they were not ordered, did not administer resident's gastrostomy tube (G-tube; a tube inserted into the stomach that brings nutrition/medications directly into the stomach) medication correctly or ensure tube feeding infused per order, did not prime an insulin pen prior to administration to ensure the correct dose was administered and did not check vital signs as ordered before the administration of medications. The facility census was 54. Review of the on-line Enteral Nutrition Practice Recommendations, a comprehensive guide developed by an interdisciplinary task force in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure four residents (Residents #9, #21, #28, and #206), in a review of 20 sampled residents, who required assistance with activities of daily living (ADLs), received the necessary care and services to maintain good grooming and personal hygiene. The facility census was 54. Review of the facility policy titled, Dental Care, revised 2021, did not address expectations of staff providing oral care to residents. Review of the facility's undated document titled, Oral Hygiene Skills Check, showed for the unconscious resident - repeat oral hygiene as often as necessary to keep the mouth and lips clean and moist. Review of the Nurse Assistant in a Long Term Care Facility manual, Revision November 2001, showed the following: -Purposes of oral hygiene (mouth care)-A clean mouth and properly functioning teeth are essential for physical and mental well-being of the resident: Prevent infections in mouth, Remove food particles and plaque, Stimulate…

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 three residents (Residents #1, #21, and #32), in a review of 20 sampled residents, were provided an ongoing activities program in accordance with the resident's comprehensive assessment, care plan, and the resident's preferences, designed to meet their individual interests and their physical, mental, and psychosocial well-being. The facility census was 54. Review of the Nurse Assistant in a Long Term Care Facility manual, revised November 2001, showed the following: -Responsibilities of the nurse assistant in resident activities: -Suggest activities of interest to the resident in a positive, enthusiastic way; -Check activity calendar daily and plan care accordingly. Encourage resident to select activities of personal interest to attend; -See that the resident is toileted, clean, and properly dressed before taking him/her to the activity; -See that the resident goes or is taken to the proper place at the right time; -See that the…

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

Based on observation, interview, and record review, the facility failed to ensure inventories of schedule II controlled substance medication (substances in this schedule have a high potential for abuse which may lead to severe psychological or physical dependence) were securely stored behind two locks when staff that received the medications left the narcotic controlled substances on a desk and unattended. The medications came up missing as a result. Further review showed the current Director of Nursing (DON) stored oxycodone immediate release (IR), a schedule II narcotic controlled substance for pain, in his office with no accountability. The facility census was 54. Review of the facility CONTROLLED SUBSTANCE POLICY, revised 2/2021, showed the following: -Controlled substances are subject to special handling, storage, disposal and record-keeping requirements. The facility will maintain compliance with these special provisions; -PROCEDURES: 1. Controlled substances in Schedules II, III and IV are subject to special handling, storage, disposal and record-keeping requirements. Such…

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 insulin (medication used to treat diabetes) pens for two residents (Residents #8 and #32), were dated when opened and/or discarded within the designated time frame after opening. Further review showed the facility failed to discard expired stock medications and staff administered the expired medication to one resident (Resident #32). The facility census was 54. Review of the Food and Drug Administration guidelines for Novolog (insulin), Levemir (insulin) and Lantus (insulin) showed the following: -Novolog Insulin should be discarded 28 days after opening; -Lantus Solostar pens should be discarded 28 days after opening. The facility provided no policy regarding insulin administration, storage or destruction. 1. Review of Resident #32's July 2022 Physician Order Sheets (POS) showed the following: -Lantus Solostar (injectable diabetic medication) 13 units (u) every day; discard the remainder of this medication 28 days after first use; -Novolog (injectable diabetic medication) every six hours per sliding…

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 followed the menu by not preparing or serving all food items for lunch as directed by the spreadsheet menu on 07/07/22. The facility census was 54. Review on 07/07/22 of the facility policies showed no documentation of a policy for following the menu. Review of the diet spreadsheet for lunch on 07/07/22 showed the following: -Residents on a pureed diet were to receive pureed roll and pureed cream cheese brownie; -All residents, except low concentrated sweet and heart healthy diets, were to receive cream cheese brownie. Review of the Diet Roster-By Diet, dated 07/07/22, showed five residents with a physician's order for a pureed diet. Observation on 07/07/22 at 10:23 A.M. showed staff prepared pureed rolls and cream cheese brownies, including pureed cream cheese brownies, for the lunch meal. Observation on 07/07/22 between 11:52 A.M. and 12:38 P.M., during the lunch meal service, showed staff did not serve pureed rolls to the residents on a pureed diet. Staff did not serve cream cheese brownies 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 prepared and served food at a safe and appetizing temperature. The facility census was 54. Review on 07/07/22 of the facility policies showed no documentation of a policy for food temperatures. Observation on 07/07/22 at 11:52 A.M. of the dining room showed staff served residents the noon meal from the steam table which included meatloaf and peas. Observation on 07/07/22 at 12:46 P.M. of the test tray, received after the last resident was served, showed the following food temperatures: -The peas were 103 degrees Farenheit (F) and cool to taste; -The pureed peas were 111 degrees F and cool to taste; -The ground meatloaf was 104 degrees F and cool to taste. During interview on 07/07/22 at 1:02 P.M., Dietary staff A said the food should be served at 165 degrees F so it was not too hot. The food did not keep temperature because the steam table cover had been taken off to serve the food. During interview on 07/07/22 at 1:10 P.M., the dietary manager said she expected the food to be served at at least…

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 ensure corridors were equipped with firmly secured handrails on each side of the hall. The facility census was 54. Observations on 7/5/22 between 10:57 A.M. and 4:33 P.M. and on 7/6/22 at 2:53 P.M. showed the following: -A 6-foot section of handrail outside resident room [ROOM NUMBER] was loose from the wall and not secured; -A 3-foot section of handrail outside resident room [ROOM NUMBER] was loose from the wall and not secured; -A 2-foot section of handrail outside resident room [ROOM NUMBER] was loose from the wall and not secured; -A 3-foot section of handrail between resident room [ROOM NUMBER] and 304 was loose from the wall and not secured; -A section of handrail between room [ROOM NUMBER] and room [ROOM NUMBER] was loose and moved slightly when grasped; -A 3-foot section of handrail outside resident room [ROOM NUMBER] was loose from the wall and not secured; -Two 3-foot sections of handrail outside resident room [ROOM NUMBER] were loose from 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 ensure a resident's choice of code status (full code (if the heart stops beating or breathing ceases, all life saving methods are performed) or no code (do not resuscitate (DNR), no life prolonging methods are performed)) was consistent and without conflicting information, throughout two residents' (Resident #32 and #206's) medical records, in a review of 20 sampled residents. The facility census was 54. Review of the facility policy titled, Advance Directives, revised February 2021, showed the following: 1. Prior to or upon admission of a resident to our facility, the Social Services Director or designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives; 3. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident,…

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 a significant change in status assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment, required to be completed by facility staff, for one residents (Resident #34), in a review of 20 sampled residents, within 14 days after the facility determined, or should have determined, there had been a significant change (major decline or improvement in the resident's status) in the resident's physical or mental condition which had an impact on more than one area of the resident's health status, and required interdisciplinary review and/or revision of the care plan. The facility census was 54. Review of the facility policy titled, Care Planning - Interdisciplinary Team Policy, reviewed February 2021, showed the following: -Policy: Every resident will be assessed using the Minimum Data Set (MDS) according to the guidelines set forth in the Resident Assessment Instrument (RAI) manual; -Purpose: 1) To assess each resident's strengths,…

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 complete a thorough assessment of one resident (Resident #2), in a review of ten sampled residents, upon admission to ensure identification and appropriate services were in place to address the resident's needs. The resident was admitted to the facility from the hospital following the amputation of toes on his/her left foot on 12/8/22. The facility did not conduct a skin assessment, did not remove dressings on the resident's foot, and did not obtain orders to treat the surgical wounds on the resident's left foot until 12/13/22 (five days following admission). The facility census was 58. Review of facility's undated New admission Process Checklist showed the following: -Complete full skin assessment; -Call physician and verify medication orders. 1. Review of Resident #2's hospital records showed he/she under went surgical procedure to remove toes of his/her left foot on 11/14/22. Review of the resident's face sheet, dated 12/8/22, showed the…

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

Based on observation, interview, and record review, the facility failed to follow proper sanitation and food handling practices. The facility census was 58. 1. Review of facility's policy Food Safety, dated 2006, showed the facility will provide food that is free from contamination thus risking the health and well being of the residents and staff. Review of facility's policy Employee Hygiene, dated 2006, showed employees must keep their hands, arms and fingernails clean. 2. Observation on 8/19/19 at 11:21 A.M. showed a bag of pre-cubed potatoes sat on the food preparation table. There were multiple areas of greenish-gray spots on the cubed potatoes with white fuzz around the greenish-gray areas. Observation on 8/19/19 at 11:44 A.M. showed Dietary Staff X cut open the bag of pre-cubed potatoes and dumped the entire bag into a metal pan and set the pan on the preparation table. Observation on 8/19/19 at 11:47 A.M. showed Dietary Staff N picked up the pan of potatoes, added cold water to the pan, and set them on the counter near the oven. During interview on 8/19/19 at 11:55 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 observation, interview, and record review, the facility staff failed to create an environment that was respectful of the rights of each resident to make choices about aspects of their lives that were significant to the resident when the facility removed partial side rails from the residents' beds which the residents used as assistive devices while in their beds for two residents (Residents #16 and #43), in a review of 15 sampled residents, and for one additional resident (Residents #58). The facility also failed to evaluate residents' preferences for time to awaken for three residents (Residents #19, #21, and #57) and for four additional residents (Residents #56, #9, #52, and #32). The facility census was 58. 1. Review of the facility policy Proper Use of Beds and Bed Mobility Systems, dated 4/2018, showed the following: -Purpose: The purpose of these guidelines is to ensure the safe use of all beds and bed mobility systems as resident mobility aids; -Mobility Systems are defined as any mechanical,…

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 surety bond sufficient (an amount equal to at least one and one half times the average monthly balance of the resident's personal funds), to ensure protection of the resident funds. The facility census was 58. 1. Review of the facility Resident Personal Trust Funds Policy & Procedures dated 1/2018 showed the following: -Policy specifications: To establish guidelines and maintain a system for protecting resident funds which assures a full and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf; Standards: 10. The Office Manager will make arrangements for an interest-bearing account which will be used for the sole purpose of resident personal funds in excess of $50.00 and will assure that such accounts remain separate from any facility operating accounts; 13. The facility shall maintain a surety bond to protect resident personal funds and the insurance certificate will be kept on file in the Administrator's…

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

Based on observation, interview, and record review, the facility failed to provide a comfortable homelike environment and ensure the resident dining room temperature remained between a temperature range of 71 degrees to 81 degrees Fahrenheit (F). The facility census was 58. Record review of the resident council minutes, dated 7/25/19, showed residents said the air conditioning needed adjusted in the dining room. Record review of the resident council minutes, dated 7/29/19, showed residents said the following: -The dining room was cold; -The air conditioning needed adjustment in the dining room; -Departmental response was that dietary staff was to notify maintenance about the temperatures being cold. Observation on 8/19/19 at 12:09 P.M. of the main dining room showed the following: -Eighteen residents were in the dining room eating their noon meal; -Ten residents complained the temperature in the dining room was cold; -The thermostat on the wall read 62 degrees F. Observation on 8/19/19 at 8:47 A.M. of the main dining room showed the following: -Nine residents were in the dining room…

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 follow standards of practice and physician orders for two residents (Residents #7 and #36), in a review of 15 sampled residents, and for three additional residents (Residents #2, #15 and #29) when staff provided treatments without a physician's order, did not follow physician orders and did not administer a resident's gastrostomy tube (G-tube; a tube inserted into the stomach that brings nutrition/medications directly into the stomach) medication correctly. The facility census was 58. 1. Review of the facility policy Medication and Treatment Order Policy, dated 2/2018, showed the following: -A physician may write orders directly in the resident's record at the time they visit the resident or dictate the order(s) to a licensed personnel while in the facility; -Telephone and/or verbal orders taken by licensed personnel from a licensed physician must be promptly recorded on the physician's orders sheet (POS) in the resident's record by the same licensed personnel receiving the order(s). 2. Review of the undated…

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 were trained and available to provide Cardiopulmonary Resuscitation (CPR) (the manual application of chest compressions and ventilations to persons in cardiac arrest, done in an effort to maintain viability until advanced help arrives) when transporting residents who requested to be full code, in the facility vehicle. Full code residents were transported by facility transporters who were not comfortable with or certified to perform CPR. The facility census was 58. 1. Review of email communication from the administrator, dated [DATE], showed the facility does not have a policy for transporters. Review of the resident list provided by the administrator showed 22 residents with full code status. During interview on [DATE] at 11:56 A.M., Transporter O said the following: -He/She transports facility residents; -He/She does not know residents' code status; -The nurse would have to tell him/her resident code status; -He/She was not currently CPR…

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 turn and reposition three residents (Residents #19, #31, and #57), who were at risk for developing pressure ulcers, in a review of 15 sampled residents. The facility census was 58. 1. Review of the Nurse Assistant in a Long-Term Care Facility, Student Reference, 2001 Revision, showed the following: -A pressure ulcer is an inflammation, sore, or lesion that develops over areas where the skin and tissue underneath are injured due to a lack of blood flow and oxygen supply to an area of the body; -This lack of circulation/blood flow and oxygen supply usually happens because of continuous pressure on the skin over a bony prominence resulting from the way or length of time a resident is positioned; pressure is the main cause; -Residents prone to forming pressure ulcers include elderly residents due to sluggish circulation, poor hydration, poor nutrition, and lack of exercise/mobility; paralyzed, thin, malnourished, obese, and incontinent…

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 washed their hands when indicated by professional standards of practice during personal care for two residents (Residents #16 and #19), in a review of 15 sampled residents and three additional residents (Resident #26, #41 and #55). The facility census was 58. 1. Review of the facility policy Handwashing Competency Evaluation revised 7/31/17 showed staff should wash hands before leaving the room, upon entering the room, after removing gloves, and before and after pericare. 2. Review of Resident #19's quarterly MDS dated [DATE] showed the following: -Unclear speech; -Rarely/never understood; -Severely impaired cognitive skills for daily decision making; -Required extensive assist of one for bed mobility; -Totally dependent on one staff for personal hygiene; -Totally dependent on two staff for transfers; -Always incontinent of bladder and bowel; -Diagnoses of dementia and psychotic disorder. Review of the resident's care plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop policies and procedures to ensure a pneumococcal vaccine program was appropriately implemented for residents, failed to assess, provide appropriate education, and vaccinate eligible residents with the pneumococcal vaccines in a timely manner as indicated by the current Centers for Disease Control (CDC) guidelines for six residents (Residents #19, #21, #31, #39, #57, and #210), in a review of 15 sampled residents. The facility census was 58. 1. Review of the facility policy Influenza and Pneumococcal Immunizations dated November 2016 showed the following: Policy: To assure that each resident receives education regarding the benefits and potential side effects before being offered influenza and pneumococcal immunizations and securing their informed consent for administration of these immunizations; Policy Specifications: 1. Each resident, or when appropriate their resident representative, will be educated regarding the benefits and potential side…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident's choice of code status was consistent throughout one resident's (Resident #57) medical records, in a review of 15 sampled residents. The facility census was 58. 1. Review of the facility policy Advance Directives, revised December 2006, showed the following: -Policy statement: Advance directives will be respected in accordance with state law and facility policy; -Should the resident indicate he/she has issued advance directives about his/her care and treatment, documentation must be recorded in the medical record of such directive and a copy of such directive must be included in the resident's medical record. 2. Record review of Resident #57's outside the hospital do not resuscitate (OHDNR) form, dated 3/12/19, showed the resident's code status as do not resuscitate (DNR). The physician had signed the DNR order. Review of the resident's medical file showed the file contained the purple OHDNR form and a facility red page…

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, facility staff failed to provide a copy of the transfer notice to a representative of the Office of the State Long-Term Care Ombudsman for one resident (Resident #4), who were transferred to the hospital, in a review of 15 sampled residents. The facility census was 58. 1. During interview on 8/22/19 at 6:00 P.M., the assistant director of nursing said the facility did not have a policy regarding notification of the Office of the State Long-Term Care Ombudsman regarding resident transfers and discharges from the facility. 2. Review of Resident #4's medical record showed the following: -The resident was sent from the facility to the emergency room and admitted to the hospital on [DATE]; -The resident was readmitted to the facility on [DATE]; -No documentation the facility notified the ombudsman of the resident's transfer to the hospital on 7/15/19. 3. During interview on 8/21/19 at 3:19 P.M., the Social Services Designee said the following: -She was responsible for resident…

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 a comprehensive discharge summary and recapitulation of stay for one resident (Resident #300), in a review of three closed records with only one requiring the recapitulation. The facility census was 58. 1. Review of the facility policy Discharge Summary and Plan, revised 8/2006, showed the following: Policy Interpretation and Implementation: 1. When the facility anticipates a resident's discharge to a private residence, or another nursing care facility, a discharge summary and a post-discharge plan will be developed which will assist the resident to adjust to his or her new living environment; 2. The discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident; 3. The post-discharge plan will be developed by the Care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide incontinence care with a urinary catheter (a sterile tube inserted into the bladder to drain urine) consistent with acceptable standards of practice, failed to maintain the catheter bag below the level of the bladder, and failed to keep catheter tubing and drainage bag off the floor for two residents (Resident #16 and #210) in a review of 15 residents. The facility identified three residents with urinary catheters. The facility census was 58. 1. Review of the facility policy Urinary Catheter Care revised September 2005 showed the following: Purpose: The purpose of this procedure is to prevent infection of the resident's urinary tract; General guidelines: 4. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder; 11. Be sure the catheter tubing and drainage bag are kept off the floor. 2. Review of the Nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to comprehensively assess pain and provide PRN (as needed) pain medication at all, or in a timely manner, prior to dressing changes, personal cares and repositioning for one resident (Resident #210) in a review of 15 sampled residents. The resident cried out in pain during dressing changes, peri care and with position changes. The facility census was 58. 1. Review of the facility policy Pain Assessment revised 8/2008 showed the following: Purpose: the purpose of this procedure is to assess the resident's pain level and provide optimal comfort through a pain control plan which is mutually established with the resident, family and members of the health care team; General guidelines: 1. A comprehensive pain assessment will be completed as part of the initial nursing assessment with development of a pain management program as indicated; 3. Continuing assessment of pain management will occur daily and will focus on the effectiveness of the program…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to assess two residents' (Resident #7 and #12) dialysis arteriovenous (AV) shunt/fistula (access used to artificially connect a vein with an artery, so that a higher blood flow is created to allow blood to be pumped out of the body to an artificial kidney machine, and returned to the body by tubes that connect the patient to the machine) daily and after the resident returned from dialysis treatments in a review of 15 sampled residents. The facility census was 58. 1. Review of the facility's policy for Post Dialysis Monitoring and Observation with Implanted A-V Shunt Policy, dated January 2018 showed the following: -Policy - Charge nurse to conduct access site observations one time per day; -Procedure - The A-V access site will be monitored during rounds; -To monitor site: Check shunt area for bruit (audible vascular sound associated with turbulent blood flow) with stethoscope. Palpitation over site should reflect a thrill. Chart on medication…

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

Based on interview and record review, the facility failed to ensure one resident's (Resident #31) in a review of 15 sampled residents, medication regimen was free of unnecessary medications. The facility failed to ensure that orders for as needed (PRN) psychotropic medications were limited to 14 days as required for Resident #31, except when his/her attending physician believed it was appropriate the PRN order be extended beyond 14 days, then the physician should document their rationale in the resident's medical record and indicate the duration for the as needed order. The facility census was 58. 1. Review of the undated facility policy Psychopharmacologic Drug Use Procedure showed the following: Procedure: 6. Dose reductions must be attempted, unless medically or psychiatrically contraindicated as documented by the interdisciplinary team and/or the physician. Dose reductions will be initially considered in two separate quarters, with at least one month between the assessments, and annually thereafter: C. Response to medication reduction must be clearly documented on a routine…

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

Based on observation and interview, the facility failed to ensure dumpsters, located next to the facility, were covered to prevent access to rodents and pests. The census was 58. Observation on 8/19/19 at 11:28 A.M. showed the facility dumpster was located outside the kitchen. The dumpster had two lids. One of the lids was open and the dumpster contained trash. Observation on 8/20/19 at 9:58 A.M. showed Dietary Staff W took the trash out from the kitchen and placed it in the open dumpster. Dietary Staff W left the dumpster open and returned to the kitchen. Observation on 8/20/19 at 4:18 P.M. showed one of the two lids to the dumpster was open and trash was visible in the dumpster. Next to the dumpster was a sign which read, CAUTION WATCH FOR WILDLIFE IN CONTAINER. Further observation showed a squirrel on top of the dumpster pulling trash out of the dumpster. During interview on 8/21/19 at 2:34 P.M., the administrator said he would expect staff to follow regulations and policy in to order to reduce the attraction of wildlife to the dumpster.