Belleview Care Center

Based on observations, interviews, and record review, the facility failed to ensure that it maintained essential equipment in a safe and operable working condition. Specifically, when the large walk-in freezer had been left with a build-up of ice on the freezer floor and on the ceiling of the walk-in freezer, which left the the walk in freezer with elevated temperatures for several days, while it was defrosting. This had the potential to affect all residents due to the health risks associated with serving foods that had been thawed for an unknown period of time. The facility census was 82. The facility did not provide a policy on maintaining kitchen equipment. Observation on 2/09/25 at 10:12 A.M. showed: -Missing freezer temperature logs from 2/7 to 2/9; -A measurement of 20 inch by 30 inch and 1/4-inch-thick area of ice buildup on the freezer floor in front of the back wall of the walk in freezer; -Icicles and frost build up on ceiling under freezer fans; -Thermometer inside the freezer read 28 degrees Fahrenheit, rather than the 0 degrees Fahrenheit recommended by the FDA (Food…

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 #36 and Resident #79 had access to a call light while lying in bed to prevent potential accidents by allowing these residents to summon staff as needed. This affected two of the 18 sampled Residents. The facility census was 82. Review of the Facility's Call Light Policy- Accessibility and Timely Response, dated 09/1/21, showed: -Assurance that the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. Cal lights will directly relay to a staff member or centralized location to ensure appropriate response. -Each resident will be evaluated for unique needs and preferences to determine any special accommodations that may be needed in order for the resident to utilize the call system. -Special accommodations will be identified on the plan of care and provided accordingly touchpads, larger buttons, bright colors. -With each interaction…

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 clarify the status of Resident #10's Do Not Resuscitate Order (DNR, medical order that instructs the health care provider not to do resuscitative measures if a person's heart stops) when the resident signed the DNR authorizing no life saving measures be taken and also signed the revocation provision of the DNR, stating the resident wanted life saving measure to be taken. This affected one (Resident #10) of 18 sampled residents. The facilty census was 83. Review of the facilty's policy titled, Resident Rights Regarding Treatment and Advance Directives, dated, [DATE], showed: -This facilty supports the resident's right to request, discontinue or refuse treatment; -The facilty supports the resident's right to formulate an advance directive; -On admission it will be determined if the resident has executed an advance directive or would like to formulate one; -Periodically the facilty will identify and clarify if the resident would like to make any changes.…

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 services that met professional standards of practice when staff failed to record the administration of medications on the Medication Administration Record (MAR) for one (Resident #13) of 18 sampled residents. The facility census was 83. Review of the facilty's policy titled, Medication Administration, dated, 09/01/22, showed: -Medications are administered by legally authorized staff as ordered by the physician in accordance with professional standards of practice; -Sign the MAR after the medication has been administered; -Document any adverse effects or refusals. Review of the facilty's policy titled, Medical Provider Orders, dated, 04/07/22, showed staff should follow all medical provider orders. 1. Review of Resident #13's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 01/02/25, showed: -No cognitive impairment; -Dependent with all Activities of Daily Living (ADLs) and transfers; -Always incontinent of bowel and bladder; -Takes scheduled and as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assure that two residents (Resident's #36 & #13) who needed respiratory care, was provided respiratory care consistent with professional standards of practice, when the facility staff failed to follow Physician orders for continuous oxygen therapy for Resident #36, and additionally, failed to assure that staff delivered a clean oxygen oxygen concentrator with oxygen tubing supplies for Resident #13. This affected two of the 18 sampled Residents. The facility census was 82. Review of the Facility's Medical Provider Orders Policy, dated 04/07/2022, showed: -It is the responsibility of all staff to follow all valid medical provider orders timely unless there is an emergency which would temporarily delay the implementation of the order. If the order is not followed the physician should be notified for clarification of the order. Review of the facility's Oxygen Policy, dated 9/1/21., showed staff are to be educated on oxygen safety precautions…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a safe/functional/homelike environment, when the facility failed to recognize and repair a leak in one resident room and one adjacent utility room, causing water to run into the room, puddle on the floor and a mold like substance to form on the ceiling and bedroom walls and in the ceiling of the utility room on the Special Care Unit. Additionally, the facility failed to adequately maintain resident safety by preventing access to the affected area. The facility census was 82. The facility did not provide a policy on wall maintenance or safety. Observation on 11/4/24 at 11:10 A.M., of room [ROOM NUMBER] showed: -The door was closed. There was no stop sign, wet floor sign, or do not enter sign; -The door knob turned easily, and the door swung open with little force; -The room had water running down the left side wall forming a large puddle approximately 6 feet across on the floor; -The left side wall had multiple dark,…

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 an alleged violation of potential physical abuse was reported immediately, but not later than two hours after the allegation was made, to officials in accordance with State law, including the Survey Agency for one sampled resident (Resident #2) out of six sampled residents. The facility census was 82 residents. Review of the facility provided policy Abuse, Neglect, and Exploitation, dated 8/22/22, showed: -It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property; -Alleged violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and if verified could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse; -Mistreatment means inappropriate treatment of a…

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

Based on interview and record review, the facility failed to follow their policy to maintain documentation and complete a thorough investigation of an alleged violation of resident abuse after informed by a staff member that one resident (Resident #2) reported a certified nurse aide (CNA) force fed him/her. This affected one of six sampled residents. The facility census was 82. Review of the facility provided policy Abuse, Neglect, and Exploitation, dated 8/22/22, showed: -It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property; -Alleged violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and if verified could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse; -Mistreatment means inappropriate treatment of a…

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

Based on observation, interviews and record reviews, the facility failed to assure staff followed acceptable standards of practice for one sampled resident (Residents #4) when staff did not notify the physician the resident was not taking his/her physician prescribed tacrolimus medication (an antirejection medication used after an organ transplant to ensure the body does not reject the donated organ). The facility census was 80. Review of the facility provided policy Medication Administration dated 9/1/22 showed: -Administer medication as ordered in accordance with manufacturers guidelines -Report and document any adverse side effects or refusals Review of the facility provided policy Notification of changes dated 9/1/21 showed: -The purpose is to ensure the facility promptly consults the residnet's physician when there is a change requiring notification -Circumstances requiring notification include: significant change in the resident's physical,mental or psychological condition that may include life threatening conditions or clinical complications. Review of the Federal Drug…

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, observation and record review, the facility failed to maintain a safe, clean, comfortable homelike environment by not maintaining the ceilings in the memory care unit. This has the potential to affect all residents who reside on the memory care unit, 22 residents. The faciilty census was 82. The facility did not provide a policy regarding maintaining the environment. Observations of the memory care unit on 3/20/24 at 1:50 P.M., showed: -A square, open hole, approximately 24 inches square, in the ceiling of the hall outside of room [ROOM NUMBER]. -A square, open hole, approximately 24 inches square, in the ceiling of area near the nurses' station. -Two square holes, approximately 12 inches square, covered with plastic sheeting, in the ceiling of the area leading from the nurses station to the dining area. -Five circular holes, approximately six inches in diameter, filled with plastic sheeting, in the ceiling of the area leading from nurses station to the dining area. During an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review the facility staff failed to ensure residents were treated in a dignified manner when four of eight residents (Resident #5, #6, #7, #8) had greasy, disheveled hair, body odor, and were wearing hospital gowns mid morning on 12/25/23. The facility census was 82. Review of the resident dignity policy dated 9/1/21 showed: - All staff members are involved in providing the residents care to promote and maintain resident dignity; - Staff were to groom and dress residents according to resident preference. Review of the resident showers policy dated 9/1/21 showed: - It is the practice of the facility to assist residents with bathing to maintain hygiene; - Residents will be provided showers per request or as the facility protocol; - Partial baths may be given between regular showers. Review of the resident rights policy dated 2021 showed the resident as the right to be treated with dignity. 1. Review of Resident #5's quarterly Minimum Data Set (MDS, a federally mandated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, the facility failed to provide care and treatment in accordance with professional standards of practice when licensed nurse staff failed to ensure that physician's orders were carried out for four residents (Resident #1, #2, #3, and #4) when blanks were left in the medication administration record (MAR) and treatment administration record (TAR). This affected four of eight sampled residents. The facility census was 82. Review of facility charting and documentation policy, dated 7/17, showed: -All services provided to the resident, progress toward the care plan goals, and any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. -The following information is to be documented in the resident medical record: - Objective observations; - Medications administered; -…

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 answer call lights in a timely manner which affected three of 14 sampled residents, (Resident #10, #25 and #53) and failed to monitor Resident #15 to ensure he/she did not disrobe in public areas. The facility census was 56. Review of the resident's rights policy, revised 9/1/22, showed in part: - The facility will inform the resident both orally and in writing in a language that the resident understands of his/her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility; - The facility will ensure that all staff members are educated on the rights of residents and the responsibility of the facility to properly care for its residents; - The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility; - The resident has the right to be treated with respect and dignity. 1. Review of…

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

Based on observations, interviews and record review, the facility failed to consider concerns and recommendations from the resident council members and failed to communicate with the resident council regarding concerns as reported by four residents who participated in a group interview. The facility census was 56. Review of the facility's undated policy for resident and family grievances showed, in part: - It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal; - Prompt efforts to resolve include facility acknowledgment of a complaint/grievance and actively working toward resolution of that complaint/grievance; - The Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances: issuing written grievance decisions to the resident counsel; and coordinating 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.

Based on interviews and record review, the facility operator failed to ensure that residents had access to their funds for one resident (Resident #17) when the resident's daughter was unable to obtain available funds from the resident's account in order to take the resident out for shopping for two weeks. This had the potential to affect all residents the facility holds funds for. The facility census was 56 Review of the undated resident funds policy showed: - The facility will maintain a resident's personal funds that do not exceed $100 in a non-interest bearing account, interest bearing account or petty cash; - Residents whose care is funded by Medicaid will deposit the resident's personal funds in excess of $50 in an interest bearing account separate from the facility's operating accounts, and that credits all interest earned on residents' funds to that account. Review of the undated resident rights policy showed: - The resident had the right to manage his/her financial affairs; - This included the right to know, in advance, what charges a facility may impose against a resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure they established and maintained a system that ensured a full, complete and separate accounting according to accepted accounting principles and failed to establish a system that accurately provided residents with a true accounting of their statement balances and monies owed to the facility for services, which caused residents to believe their housing costs where covered, when they actually were not and the residents spent their social security checks, which should have been used for their rent to the facility. Additionally, these residents are not able to pay their rent by way of debit card, they have no access to cash, or check, and this had a negative emotional impact on two residents (Residents #25 & #51) when they worried they would now be kicked out of the facility for not paying their rent. The facility census was 56. Review of the Resident Personal Funds Policy, revised on 4/10/23., showed: - The resident has a right to manage his or her…

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 they informed residents of their rights periodically during the resident's stay both orally and in writing. The facility census was 56. Review of the facility's policy on Resident Rights dated 9/1/22 showed: - The facility will inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility; - The policy did not specifically indicate when rights should be communicated with the residents. During the resident council meeting and interview with surveyors on 8/28/23 at 10:27 A.M., all four residents in attendance said: - Resident rights are not discussed at any of the resident council meetings; - No written documentation regarding resident rights is given at resident council meetings. During an interview on 8/30/23 at 9:37 A.M., the Activities Director said: - He/she has only been employed for a couple of weeks and has only been able to attend one resident council…

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 interviews the facility failed to ensure they followed their policy when they failed to indicate residents' wishes and document the residents' choice of code status in such a way to be readily accessible and understandable to staff in the event of an emergency. This affected three of 14 sampled residents (Residents #8, #3, and #209). The facility census was 24. Review of the facility's Residents' Rights Regarding Treatment and Advance Directives policy revised [DATE] showed: - It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive; - On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive; - Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated…

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

Based on observation, record review, and interviews, the facility failed to provide a safe, clean, comfortable and homelike environment for all residents on the secured memory unit when the staff did not keep rooms clean, floors throughout the unit clean and in good repair, doors and walls in all the hallways and in resident rooms scuffed with missing paint. Additionally the unit, lacks a homelike environment with no decor, and has furniture being actively used by residents that is in need a replacement or repair. The facility census was 56. A housekeeping policy was not provided. Review of the facility's Resident Rights policy., dated 9/1/22 showed: -The resident has the right to a dignified existence. Observation of the memory unit on 8/27/23 at 10:22 A.M., showed: - The doors entering into the secured memory unit have papers taped to cover the windows so the residents can look out. These doors on both sides have missing paint. - One open area that is not being used by residents has floor striped and waxed recently. - The floors of the unit have dirty wax build up and sticky…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure staff provided a written notice of transfer or discharge to residents or their responsible parties and the reasons for the transfer, in writing and in a language they understood. The notice should include the effective date of discharge or transfer the location to which the resident is transferred or discharged ; a statement of the resident's appeal rights, including the name, address (mailing and electronic mail), telephone number of the entity which receives requests and information on how to obtain the appeal form and assistance in completing and submitting it; the name, address (mailing and electronic mail) and telephone number of the Office of the State Long-Term Care Ombudsman; and for residents with a mental disorder or related disabilities, the mailing, electronic mail (e-mail) address and telephone number of the agency for protection and advocacy for individuals with mental disorders established under the Protection and Advocacy for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop and implement a comprehensive plan of care which included measurable objectives and time frame's for two out of the 14 sampled residents, (Resident #209 and Resident #25). The facility staff failed to implement any comprehensive person-centered plan of care that addressed the needs for resident #209 and failed to develop a care plan to address Resident #25's diagnosis of a Post-Traumatic Stress Disorder (PTSD, a disorder that develops in some people who have experienced a shocking, scary, or dangerous event). The facility census was 56. Review of the facility's Baseline Care Plan policy dated, 9/1/21 showed: - The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care; - A baseline care plan will be developed within 48 hours of a resident's admission; - The care plan will include…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure they provided care and treatment in accordance with professional standards of quality when nursing staff failed to follow physician orders by not ensuring they applied tubi grips daily in the morning for one of 14 sampled residents (Resident #8) and failed to obtain an order to provide oxygen therapy for two of 14 sampled residents who were observed on oxygen (Resident #3 and #209). The facility census was 56. Review of the facility's Medical Provider Orders policy, revised 4/7/22, showed: - The facility shall use uniform guidelines for the ordering and following of medical provider orders; - Medications and/or treatments should be administered only upon the signed order of a person lawfully authorized to prescribe; - Verbal orders should be received only by licensed nurses, or pharmacists, and confirmed in writing by the medical provider, on the next visit to the facility; - Needed elements of the medication and/or treatment order…

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 five of 14 sampled residents who required staff assistance (Residents #8, #10, #11, #25, and #53), were provided with adequate assistance for activities of daily living (ADL's: tasks completed to care for oneself daily such as bathing, dressing, moving from a chair to bed, and personal hygiene), as well as failed to provide appropriate incontinent care for residents (#25 and #53) and failed to provide showers to maintain personal hygiene for all five of the identified residents. The facility census was 56. Review of the facility's Activity of Daily Living Policy, dated 9/1/21., showed: - The facility will ensure a resident's abilities in ADL's (Activity of daily living) do not deteriorate unless deterioration is unavoidable. - The facility will ensure the resident's ADL needs are met. - This includes the resident's ability to bathe, dress ,and groom., transfer and ambulate; toilet; eat and use speech to communicate. Review of the…

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

Based on observation, interview and record review , the facility failed to provide an ongoing program to support residents in their choice of activities to meet the interests and well-being of the residents who reside in the facilities secured memory care unit. This affected all of the memory care residents. The facility census was 56. Review of the facilities Activity Policy, dated 9/1/21., showed: - It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences of each resident. Facility sponsored group and individual activities and independent activities will be designed to meet the interests of and support the physical, mental, and psychosocial well being of each resident, as well as encourage both independence and interaction within the community. - Activities will be designed to enhance quality of life, well-being, belonging, promote or enhance physical activity, emotional health, dignity, and self esteem. During an observation on 8/27/23 at 10 am, and 2 P.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 observations, interviews, and record review the facility failed to ensure staff provided proper respiratory care for five of 14 sampled residents (Residents #3, #33, #47, #110, and #209) when staff failed to: effectively clean oxygen concentrator filter area, properly install oxygen concentrator filter, properly label and date oxygen concentrator oxygen tubing, properly label and date oxygen concentrator tubing setup bags, have physician's orders for oxygen administration, clean a nebulizer mask, and failed to comprehensively care plan the use of oxygen therapy. The facility census was 56. Review of the facility's undated oxygen administration policy showed: - Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences; - Oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are…

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 provide adequate staffing to meet the needs of residents by failing to: provide showers for four of the 14 sampled residents, (Residents #8, #10, #11 and #25). The facility also failed to provide care in a timely manner to Resident #25, resulting in him/her being left waiting on bed pan for an extended period of time. The facility also failed to ensure reasonable response times to call lights, resulting in extended call light wait times, which affected the four residents who attended the resident group interview. The facility census was 56. Review of the facility's undated policy on Nursing Services and Sufficient Staff policy showed: - It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility's census, acuity and diagnoses 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 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 three medication errors out of 27 opportunities for error which resulted in a medication error rate of 11%, which affected two sampled residents, (Resident #4, #25). The facility census was 56. Review of the facility's undated Insulin Pen policy., showed: - It is the policy of this facility to use insulin pens in order to improve the accuracy of insulin dosing, provide increased resident comfort, and serve as a teaching aid to prepare residents for self-administration of insulin therapy upon discharge. - Insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir. - Prior to attaching the needle to the pen, remove the pen cap, wipe the rubber seal with an alcohol pad then screw the pen needle onto the insulin pen, twist open and remove outer cover from the pen needle. -Prime the insulin pen by dialing 2 units by the dose selector clockwise, with the needle pointing up,…

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

Based on observations, interviews, and record review, the facility failed to ensure staff discarded expired stock medication stored in the medication room, failed to ensure there was no food in the medication refrigerator, failed to ensure opened insulin pens and vials were dated, failed to ensure food and medications where not stored together and failed to ensure medication refrigeration was monitored for appropriate temperatures. The facility census was 56. Review of the facility's Medication Storage policy dated, 9/1/21., showed: - It is the policy of this facility to ensure all medication housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. - All stored medications will be routinely inspected by the consultant pharmacist for discontinued, outdated, defective or deteriorated medications with worn, illegible, or missing labels. These medications are to be destroyed. - Refrigerated…

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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. When the facility allowed dirty, black substance stained linens to be placed in resident care areas for staff and residents use, failed to monitor linens upon delivery to the clean linen rooms by the laundry staff, failed to ensure that residents, and staff had immediate access to incontinent adult briefs. This affected three of the 14 samples residents (Resident #17, #11, #53), and failed to monitor staff on appropriate hand washing and peri care processes for two of sampled 14 residents (Resident #4 and #53 ) As well as additionally failed ensure that new staff had completed a Tuberculin skin test prior to working. The facility census was 56. Review of the facility's Infection Prevention and Control Program Policy,…

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 accommodate the needs and preferences of Resident #209 when they failed to provide a chair of sufficient size and structure to accommodate the stature of the resident. Resident #209 was one out of 14 sampled residents. The facility census was 56. Review of the facility's undated Accommodation of Needs policy showed: - The facility will treat each resident with respect and dignity and will evaluate and make reasonable accommodations for the individual needs and preferences of a resident, except when the health and safety of the individual or other residents would be endangered; - The facility will make reasonable accommodations to individualize the resident's physical environment including their personal bathroom and bedroom and the common living areas within the facility; - Facility staff shall make efforts to reasonably accommodate the needs and preferences of the resident as they make use of their physical environment; - Based on individual needs and preferences, the facility will assist the resident 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 record reviews and interview the facility failed to ensure they completed a Criminal Background Check (CBC) for one staff member (Certified Nurse Aide B), and the Missouri Certified Nurse Aide (CNA) Registry for eight staff members (Certified Nurse Aides B, C, D, and E); Nurse Aides A, B, C, and D) of the eight sampled staff members. The facility census was 67. Review of the facility policy, Abuse, Neglect, Misappropriation, Exploitation Policy, dated January 2019, showed: -Each center will follow any and all state specific requirements. -Potential team members shall, at a minimum, have the following screenings checks conducted: appropriate licensing board or registry check and criminal background check pursuant to company policy or state law. -The center will not retain any team member with a history of abuse or neglect if that information is known to the center. -The center must not employ or otherwise engage individuals who have had a disciplinary action taken against a professional license by a state licensure body of had a finding entered into the state NA registry…

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 provided a written notice of transfer or discharge to residents and their responsible party and the reason for the transfer/discharge in writing in a language they understood. This affected three of the seventeen sampled residents. (Residents #12, #30 and # 58). The facility census was 67. Review of the facility's transfer and discharge policy, dated November 1, 2016 showed in part: Before Diversicare transfers or discharges the Resident, it shall notify the Resident and the Resident's Representative of the basis for the transfer or discharge in a language and manner they understand; and will also notify the State Long-Term Care Ombudsman. The Notice of Transfer shall include the information required under the law, including the Resident's appeal rights, and shall be provided at least 30 days before the proposed date of transfer or discharge unless sooner notice is permitted. Notice may be made as soon as practicable before a transfer or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to inform the resident and the resident's family/legal representative of the facility's bed-hold policy at the time of transfer/discharge to the hospital. This affected three of the seventeen sampled residents. (Residents # 12, # 30, and # 58). The facility census was 67. Review of the facility's bed hold policy dated November 1, 2016 includes: - The facility will, in accordance, with Federal and State regulations, hold a Resident's bed during a temporary hospitalization or therapeutic leave. - Before the Center transfers a resident to a hospital or the resident goes on a therapeutic leave, the facility shall provide the resident or his or her representative the bed hold policy. 1. Review of Resident #12's quarterly minimum data set (a federally mandated assessment completed by facility staff) MDS, dated [DATE], showed: -BIMS score 12. This indicates moderate cognitive impairment. -Resident is a two person assist and requires assistance with activities 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 comprehensive care plans were developed and updated as needed to reflect urinary catheters (a flexible tube used to empty the bladder and collect urine in a drainage bag), oxygen, depression, and anticoagulants (blood thinner). This affected three residents (Resident #44, #24, and #47). Facility census was 67. The facility did not provide a policy for care plans. The Director of Nursing (DON) referred to Centers for Medicare and Medicaid Services (CMS) guidance regarding care plans. 1. Review of Resident #44's quarterly minimum data set (MDS, a federally mandated assessment completed by facility staff), dated 12/2/21, showed: -Brief interview for mental status (BIMS) score 15. This indicates no cognitive impairment. -Diagnosis include: stroke, coronary artery disease (when the major blood vessels that supply your heart become damaged or diseased), hemiplegia or hemiparesis (Hemiparesis is a mild or partial weakness or loss 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 staff provided respiratory care to two residents (Residents #24 and 58) as ordered by the physician, and failed to properly maintain clean portable oxygen concentrator tubing in room [ROOM NUMBER]. Facility census was 67. The facility did not have a policy regarding following physician orders. The facility did not have a policy regarding respiratory care. Review of the facility policy, Oxygen Tubing, not dated, did not address storage of tubing when not in use. 1. Review of Resident #24's quarterly minimum data set (MDS, a federally mandated assessment completed by facility staff) dated 11/16/21, showed: -Brief interview for mental status (BIMS) not done. This indicates severe cognitive impairment. -On oxygen therapy. -Diagnosis include: non-traumatic brain dysfunction, dementia, and anxiety. During an observation on 01/03/22 at 11:27 A.M. showed: -Oxygen on via nasal cannula at three liters. During an observation on 1/11/22 at…

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

Based on interview and record review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day seven days a week who was not the Director of Nursing (DON). The facility maintained a census of greater than 60 residents and this deficiency had the potential to affect all residents. The census was 67. The facility did not have a policy regarding staff scheduling related to RN coverage. Review of facility staffing sheets showed no RN coverage, other than the DON, on the following days: -12/19/21, -11/7/21, -11/27/21, -11/28/21, -10/10/21, -10/24/21. During an interview on 1/5/22 at 3:00 P.M. the DON, Assistant DON, and the Administrator said: -The DON is utilized to provide RN coverage. -They were not aware that DON could not serve as the RN coverage due to average daily census over 60. During an interview on 1/6/22 at 3:30 P.M. the Administrator said: -He/She was unaware that the DON could not serve as the RN coverage requirement with a census of 60 and above. -He/She submits reports for staffing through corporate and no one in corporate has ever said…

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 a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases when staff failed to ensure catheter bags were kept from touching the floor for one resident (Resident #47), failed to ensure staff conducted hand hygiene during peri-care for one resident (Resident #50), and failed to ensure two staff members screened for COVID symptoms prior to working with residents (Certified Nurses Aide (CNA) F and CNA G). Facility census was 67. 1. Review of facility audit tool for Indwelling Catheters, undated, did not address catheter bags touching the floor. The facility did not provide any other catheter related policy. Review of Resident #47's quarterly minimum data set (MDS, a federally mandated assessment completed by facility staff), dated 12/8/21, showed: -Brief Interview for Mental Status (BIMS) not completed. This was due to severe cognitive impairment. -Always incontinent 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.

Based on observation, interview, and record review, the facility failed to ensure residents with pressure ulcers received treatment as ordered for two residents (Resident #12 and #50) and services to prevent the development of pressure ulcers for one resident (Resident #12). The facility census was 67. Review of facility policy, Skin Care Guidelines, dated July 2018, showed: -All those admitted will be observed for baseline skin condition and evaluated for risk of skin breakdown. -Weekly review of the resident's skin will be completed by the nurse and documented in the medical record. -Residents will be observed by nurse aide team members daily for changes in skin condition. Changes will be reported to the licensed nurse and documented in the medical record. -Director of nursing or designee will be responsible to implement and monitor the skin integrity program. -The plan of care will address problem, goals, and interventions directed toward the prevention of pressure ulcers in those at risk and for any skin integrity concerns identified. -When an open area is identified: document…

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

Based on interview and record review, the facility failed to ensure staff documented post-fall evaluations when one resident (Resident #121) suffered multiple falls. Facility census was 67. Review of facility policy, Falls, not dated, showed: -Post fall: the patient is physically assessed for injuries and medical attention rendered as needed; the physician and resident's representative are notified of the fall; the post fall evaluation is completed to assist in developing interventions to prevent future falls; the interdisciplinary team reviews post fall investigations and summarizes recommendations for interventions. Review of Resident #121's admission minimum data set (MDS, a federally mandated assessment completed by facility staff), dated 11/18/21, showed: -Brief interview for mental status (BIMS) score of 3. This indicates severe cognitive impairment. -One staff assist for walking and locomotion. -Diagnosis include Alzheimer's disease. -Falls marked in the care area assessment. -No falls since admission. -History of a fall within the last month prior to admission. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a system to monitor for weight loss for one resident (Resident #50). Facility census was 67. Review of facility policy, Weight Loss Interventions, dated December 2010, showed: -Nutritional supplements will be provided as ordered when supplements are required to maintain nutritional adequacy and/or when resident suffers from weight loss and other means of improving nutrition and/or intake. -When a resident loses three percent of more in one month, or is significantly below ideal/usual body weight, the following steps shall be taken: if the weight is questionable, re-weigh the resident; review causes for poor consumption during the weekly focus meeting; when contributing factors have been identified, appropriate interventions will be implemented; the resident will be weighed weekly for four weeks; -If weight has not stabilized or if the resident has lost five percent in one month, 7.5% in three months, or ten percent in six months,…

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 assist one resident (Resident #50) in obtaining dental care. Facility census was 67. The facility did not have a policy to address Dental Services. Review of Resident #50's significant change minimum data set (MDS, a federally mandated assessment completed by facility staff), dated 12/15/21, showed: -Brief interview for mental status (BIMS) score of 15. This indicates no cognitive impairment. -Diagnosis include: cirrhosis (chronic liver damage leading to scarring and liver failure), renal failure, urinary tract infection (UTI, last thirty days), diabetes, thyroid disorder, fracture, cerebral palsy (congenital disorder of movement, muscle tone, or posture, due to an abnormal brain development), and depression. -No swallowing disorder. No or unknown weight loss. -No dental concerns. During an interview and observation on 1/3/22 at 2:00 P.M. the resident said: -He/she has bad teeth, some bottom teeth missing, loose teeth on the top and bottom. -The CPAP machine dries up his/her mouth and his/her teeth hurt.…

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.