St Joseph Chateau

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to serve food to the residents that was palatable, attractive, and served at a safe and appetizing temperature. This affected three out of 16 sampled residents residents (Resident #33, #34, and #47). The facility census was 62. Review of the facility's Food Temperatures at Point of Service, reviewed 7/14/23, showed: -Food will be prepared, held and served in a manner that preserves nutritive value and palatability; -Hot foods will be held at 135 degrees Fahrenheit or above and cold foods will be held at 41 degrees Fahrenheit or below prior to serving to maintain food safe; -Best efforts will be made to present hot food hot and cold food cold at point of service by using thermal lids and bases, heated or chilled plates and thermal pellets as necessary; -Food service staff will monitor palatability of food at point of service by periodic test tray evaluation and review of resident council concerns. 1. Review of the resident's #34's Quarterly…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff prepared foods in a consistency designed to meet the needs of individual residents, when they did not ensure the pureed (a texture-modified diet in which all foods have a soft, pudding-like consistency) food had a smooth and appropriate consistency. This affected three out of 16 sampled residents (Residents #5, #19, and #47) by causing a choking hazard. The facility census was 62. The facility did not provide the requested policy on pureed food preparation. Review of the facility's Medical Provider Orders Policy, revised 4/7/22, showed: Staff should follow all medical provider orders timely. Review of the facility's undated Therapeutic Diets Policy showed: -Mechanically altered diets will be considered therapeutic diets; -A therapeutic diet must be prescribed by the physician. 1. Review of the Resident #5's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/9/24,…

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

Based on observation, interviews, and record review, the facility failed to ensure staff stored food in a sanitary manner and failed to maintain the kitchen in a sanitary manner when the ceilings, walls, floors, and vents were covered in dirt and debris, and when the walls, floors and ceilings were not in good repair, and when the freezers were not clean, and contained opened and undated food. This could potentially impact all residents by dirt or debris coming in contact with food and food preparation areas. Additionally food that is open and undated can be potentially hazardous due to spoilage. The facility census was 62. Review of the facility's undated Cleaning Ceilings policy showed: -Ceilings will be cleaned to avoid soil build-up; -Vacuum ceilings; -Remove all cobwebs; -All light shields shall be cleaned and cleared of all debris; -Ceilings shall be cleaned as necessary or at a minimum of twice a year. Review of the facility's undated Sanitation of the Dietary Department showed: -The dietary staff shall maintain the sanitation of the dietary department through compliance 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 record review and interviews the facility failed to maintain quarterly quality assessment committee (QAA) meetings with the required members. The facility census was 62. Review of the facility policy Quality Assurance and Performance Improvement (QAPI) dated 9/1/2021 showed: -The Quality Assessment and Assurance (QAA) committee shall be interdisciplinary and shall consist of a minimum of the Director of Nursing, the Medical Director or his/her designee, the infection preventionist and at least three other members of the facility staff. Shall meet at least quarterly Review of the facility provided sign in sheets for April 2023 through March 2024 showed: -The committee had meetings April 2023, June 2023, October 2023, January 2024 and March 2024 -The Medical Director signed as attending June 21, 2023 and March 1, 2024. -There was no sign in sheet for the quarter between June 2023 and October 2023 During an interview on 3/28/24 at 4:57 P.M. the Director of Nursing said: -She does not know who is responsible for QAA and QAPI as the coordinator. -She attends meetings and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Observation, record review and interview showed the facility failed to follow infection control standards and guidelines for medication administration when staff touched medications with ungloved hands for two residents (Resident #41 and #36). Additionally staff failed to provide annual tuberculosis testing for three residents (Resident #20, #24 and #47) ) of 16 sampled residents. the facility census was 62. Review of the facility provided policy Medication Administration, revised 9/1/22 showed: - Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection; - Remove medication from source, taking care not to touch medication with bare hand. Review of the facility provided policy Infection Prevention and Control Program, reviewed/revised 5/15/23 showed: -This facility has established and maintains an infection prevention and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program to prevent gnats facility wide and mice droppings in two residents' rooms (Resident #24 and Resident #55), potentially effecting all residents. The facility census was 62. Review of the facility provided policy Pest Control reviewed/revised 9/1/22 showed: -It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents (e.g. mosquitos, flies, mice and rats). Observation on 3/25/24 at 11:47 A.M., showed on the 200 hallway there were multiple gnats in various resident's rooms. Observation on 3/25/24 at 12:02 P.M. showed there were multiple gnats in the dining room. Observations on 3/27/24 at 10:18 A.M. showed there were multiple gnats in the hall, the beauty shop, and front office area. During an interview on 3/28/24 at 10:03 A.M. Certified Nurse Aide A said: - He/She picked up wet sheets that morning and there were a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff did not provide complete perineal and urinary catheter care to two of 16 sampled residents, (Resident #20 and #33). The facility census was 62. The facility did not provide a policy for perineal care or catheter care. 1. Review of Resident #20's Annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/15/24 showed: - Long and short term memory problems; - Upper and lower extremities impaired on one side; - Dependent on staff for toilet use, dressing and transfers; - Always incontinent of bowel and bladder (the inability to control urine or bowel movements) - Diagnoses included aphasia (a language disorder that affects a person's ability to communicate), stroke, dementia, seizure disorder, anxiety, depression, hemiplegia…

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 supervision while eating for one resident out of 16 sampled residents (Resident #5) who is a choking risk while dining in his/her room per the resident's care plan. The facility census was 62. The facilty did not provide the requested policy on accidents. 1. Review of the Resident #5's care plan dated 10/23/23, showed: - ADL self-care performance deficit due to right sided hemiplegia; -The resident is dependent on staff for meeting emotional and physical needs related to cognitive deficits; - The resident has had choking episode while eating related to dysphagia (difficulty swallowing); - The resident is to be monitored by staff while eating. Review of the resident's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/9/24 showed; - Severe cognitive impairment; - Substantial assistance with Activities of daily living (ADLs); - The resident had hallucinations (a false…

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 prevent significant weight loss of more than 10% of the resident's body weight in a 3 month period for one sampled resident who was at nutritional risk and received dialysis (Resident #3) out of 16 sampled residents. The facility census was 62 residents. Review of the facility provided policy Weight Monitoring, dated 9/1/22 showed: -Based on the resident's comprehensive assessment the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual or desirable body weight. -Interventions will be identified, implemented, monitored and modified (as appropriate), consistent with the resident's assessed needs, choices, preferences, goals, and current professional standards to maintain acceptable parameters of nutritional status. -A significant change in weight is defined as: 5% change in weight in 1 month (30 days), 7.5% change in weight in 3 months (90 days), 10% change in weight in 6 months (180 days). -The physician should be informed of a significant change 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 interviews, the facility failed to provide resident representatives and health care professionals access to residents when the facility failed to have continuous phone service available in the facility from 11/24/23 to 12/10/23. This effected two reaidents, when resident #4 was unable to make a phone call to family and when health care professionals were unable to speak to the facility's nursing staff regarding resident #1's care in the emergency room when phones were unanswered by the facility. The facility census was 63. Review of facility policy, resident rights, dated 9/1/21 showed: -Facility will inform the resident both orally and in writing in language that the resident understands of his or her rights and all rules an regulations governing resident conduct and responsibilities during the stay in the facility. 1. Review of Resident #4's quarterly Minimum Data Set, a federally mandated assessment instrument completed by facility staff, dated 10/30/23, showed: -A Brief Interview Mental Status…

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 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 when staff transferred three of eight sampled residents (Resident #1, #2, and #3) to the hospital. The facility census was 63. The facility did not provide a policy on transfer agreements. Review of facility admission packet on hospital transfers, undated, showed: -Facility will arrange for transfer of resident to a hospital when such a transfer is ordered by the attending physician or by another physician, or in the event of an emergency and a physician is not reasonably available. -Resident shall be responsible for payment of transportation charges and other costs of such transfer not paid by Medicaid program, the Medicare program of the Veterans Administration. Unless resident directs the facility otherwise, Resident conseents to Resident's transfer to any hospital at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure they provided a notice of their bed-hold policy before transferring three of eight sampled residents (Resident #1, #2, and #3) to the hospital. The facility census was 63. Review of facility's Bed Hold Agreement, undated, showed: -In the event resident is transferred for a hospitalization, therapeutic, or other permissible leave, the resident will be notified of the rate at the time the Resident is temporarily discharged , or within 24 hours in case of an emergency transfer. 1. Review of Resident #1's significant change in condition Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/1/23, showed: -A Brief Interview for Mental Status (BIMS) score of fifteen, which indicated resident was cognitively intact; -Diagnoses included pneumonia (an infection that inflames air sacs in one or both lungs which may fill with fluid), depression, anxiety disorder, schizophrenia (a disorder that affects a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff provided assistance to dependent residents with grooming and showers when they failed to provide at least two showers a week to six residents (Resident #2, #4, #5, #6, #7, and #8) of the sampled eight. The facility census was 63. Review of facility policy, activities of daily living (ADLs), dated 9/1/21, showed: -The facility will ensure a resident's abilities in ADL's do not deteriorate unless deterioration is unavoidable. -This included the resident's ability to: Bathe, dress, and groom; -A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of facility policy, bathing a resident, dated 9/1/21, showed: -It was the practice of the facility to assist residents with bathing to maintain proper hygiene and help prevent skin issues. Review of facility policy, promoting/maintaining resident dignity, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program to prevent flies. The facility census was 62. Review of the facility provided policy Pest Control Program dated 9/1/22 showed in part: -It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests (e.g. bed bugs, lice, roaches, ants, mosquitos, flies, mice and rats). -The facility will utilize a variety of methods in controlling certain seasonal pests, such as flies. These will involve indoor and outdoor methods that are deemed appropriate. During an interview on 10/5/23 at 11:03 A.M. Resident #10 said: -His/Her job was to kill flies. -He/She killed 27 flies a few days ago. -The flies crawled on everything -He/She had maggots in a wound because of the flies. -The flies are not as bad now that he/she is getting a daily bath. Observation on 10/5/23 at 11:03 A.M. room [ROOM NUMBER] showed : -Multiple flies in the resident's…

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

Based on observation, record review and interview, the facility failed to notify one resident's (Resident #10) primary care physician and medical director of a wound contaminated by maggots. The facility census was 62. The facility did not provide a policy on notification of the physician. Review of Resident #10 admission Minimum Data Set (MDS: a federally mandated assessment completed by facility staff) dated 9/16/23 showed: -Brief Interview of Mental Status (BIMS) of 15: indicated no cognitive deficit. -No behaviors exhibited. -Extensive Assistance on staff for personal hygiene. -Supervision of staff for dressing, walking and using the toilet. -No pressure ulcers. -No venous/arterial ulcers. -No lesions of the foot. -Diagnosis of Congestive Heart Failure (CHF: A weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs.), hypertension, Atrial Fibrillation (an irregular heart rhythm), obesity, edema, and anxiety disorder. Review of the resident's Comprehensive Care plan dated 9/6/23 showed: -He/She had an actual impairment to his/her skin. He/She…

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 an infection control program during a Coronavirus disease 2019 (Covid-19, an infectious disease caused by severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2), to provide a safe environment for all residents. The facility failed to follow the facility's policy for infection prevention and control program when staff did not wear personal protective equipment (PPE) when entering SARS-CoV-2 positive rooms. The deficient practice affected five (Resident #1, #2, #3, #8, #10) of ten sampled residents. The facility census was 62. Review of facility policy, Infection Prevention and Control Program, dated 5/15/23, showed: -The facility has established and maintains 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 disease and infections as per accepted national standards and guidelines. - All staff 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.

Based on observation and interview, the facility failed to ensure residents knew were to find the name and phone number of the local ombudsman. The facility census was 62. Observation on all days of the survey, 4/24/22 through 4/29/22, showed a black picture frame hanging on the wall outside the administrator's office with what looked like a piece of typing paper and OMBUDSMAN typed on it along with two phone numbers. The sign did not include the name of the local Ombudsman or the address of the office. During a group meeting on 4/25/22 at 10:04 A.M., 21 residents present said they did not know the name of the local local Ombudsman. During an interview on 4/28/22 at 9:58 A.M., the Administrator said the local Ombudsman has not been here since the last one left employment. They had a volunteer but had to ask for them to not come back to the facility because of issues they had with some of the residents and how they talked to the residents. They do have the phone number posted but no other information posted.

Based on observation, record review and interview, the facility failed to store food in a sanitary manner and failed to maintain the kitchen in a sanitary manner. This had the potential to affect all residents in the facility. The facility census was 62. Review of the facility's Food Storage: Dry Goods policy, dated 9/2017, showed: -All dry good will be appropriately stored in accordance with the Food and Drug Administration (FDA) Food Code. -All items will be stored on shelves at lease 6 inches above the floor. -Foods stored on moveable racks or dollies may be stored at less than 6 inches from the floor. -Items will not be stored within 18 inches of a sprinkler unit. -The Dining Services Director or designee regularly inspects the dry storage area to ensure it is well lit, well ventilated and not subject to sewage or wastewater backflow or contamination by condensation, leakage, rodents, or vermin. -All packaged and canned food items will be kept clean, dry and properly sealed. -Storage areas will be neat, arranged, for easy identification, and date marked as appropriate. -Toxic…

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

Based on record review and interview, the facility failed to ensure they submitted their current bond to the Department of Health and Senior Services (DHSS) for approval after increasing their bond amount covering the Resident Trust Fund (RTF) account. The facility census was 62. Review of the DHSS data base, which tracks the most up to date information regarding approved bonds for RTF accounts for all facilities that hold resident monies showed an approved bond amount of $45,000 approved by DHSS on 8/9/19. Review of the Resident Funds Bonds Worksheet, a form used by DHSS to determine what the facility's bond should be and if they have the appropriate approved amount for their bond, showed: -The average balance for the previous twelve months in the facility's RFT bank account was $61,517.84 -The approved bond amount should be $93,000.00. Review of the rider from the facility's casualty insurance company who holds their RTF account bond, dated 7/1/2021, showed: -A bond increase from $45,000 to $135,000 was approved and was effected 8/10/2021. The amount of $135,000 is effective until…

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 interviews, the facility failed to ensure they maintained a safe, clean, comfortable environment for the residents when staff did not keep all areas of the facility clean and safe. The facility census was 62. Review of the facility's Deep Clean Calendar for April 2022, showed 31 resident rooms were scheduled for deep cleaning during the month along with several offices. Review of the undated Route 1 cleaning schedule showed: - 5-Step Room Cleaning: 1 Pull Trash 2 Dust Horizontals 3 Clean walls 4 Sweep floors 5 Damp mop floors - 7-Step Restroom Cleaning: 1 Check paper supplies 2 Pull trash 3 Dust mop floor 4 Clean mirror 5 Clean sink and tub 6 Clean toilet 7 Damp mop floor - check underneath/behind furniture when sweeping and mopping - Perform morning walk-thru of your area (address any spills, full trash containers, etc.) - Cross off each common area as you clean it! - Common Areas and Office to Clean (check off as you go) Public/restrooms (AM) Front Offices MDS (minimum…

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 ensure they allowed residents the opportunity to voice grievances to the facility, failed to ensure they made prompt efforts to resolve any grievances, failed to make information on how to file a grievance or complaint available to the residents, and failed to ensure they responded in writing to all grievances. The facility census was 62. Review of the facility's July 2018 policy titled Customer Concern (Grievance) policy showed the purpose of the the policy was to support each resident's right to voice concerns (grievances) and to ensure after receiving a concern, the center actively seeks a resolution and keeps the customer appropriately apprised of its progress toward resolution. The goal is to encourage open communication of customer concerns in an environment free from reprisal, retaliation or discrimination. We have a commitment to customer service and have systems in place to address concerns. Our Grievance Official is the Center Administrator. The Grievance Official's contact information including…

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 who were unable to carry out their own activities of daily living (ADLs) received the necessary services to maintain good personal hygiene, which affected two of 17 sampled residents (Residents #8 and #18). The facility census was 62. Review of the Resident's Rights and Quality of Life policy, dated 5/1/12, showed it is the policy that all residents have the right to a dignified existence, self-determination and communication with an access to people and services inside and outside the facility. The policy did not address how to ensure residents' dignity was preserved, providing showers or ensuring residents had services provided in a timely manner or according to their preferences. 1. Review of Resident #8's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/2/22, showed: - A brief interview for mental status (BIMS) score of 10 which indicated moderate cognitive…

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 ensure their activity director (AD) completed an approved training course through the State of Missouri. This affected all residents in the facility. The facility census was 62. The facility did not provide a policy regarding training for the activity director. During a group interview with residents on 4/25/22 at 10:02 A.M., 21 residents said if staff are not able to assist them with an activity, the residents usually do them themselves. Some residents will call bingo so the activity can happen. Weekends are very laid back (watch movie, coloring, word search, watch church on TV). There is not really a lot to do. They feel the AD is doing a good job, he/she just needs to be trained more on what they need. During an interview on 4/28/22 at 1:52 P.M., the AD said: - He/she has been doing activities for about one year. He/she had not been through any type of training and no class or certification program for his/her job. The Minimum Data Set (MDS) coordinator trained him/her on how to complete assessments in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents who entered the facility without limited range of motion (ROM) did not experience a reduction of their ROM when they failed to provided a restorative nursing program which affected two of 17 sampled residents (Residents #9 and #18). The facility census was 62. Review of the facility's Restorative (RA) Guideline, dated June 2019, showed restorative services refers to nursing interventions to assist the resident in reaching his/her highest level and then maintain that function. The RA program is: - Generally, RA programs are initiated when a resident is discharged from formalized therapy. - Each resident will be screened or evaluated by the interdisciplinary team (IDT) for inclusion into the appropriate center RA program when referred by therapy or the IDT. - The IDT jointly decides that the resident would benefit from a RA program based upon current functional status. - A RA program does not require a physician's 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 interviews, the facility failed to ensure they assessed residents for risk of entrapment from bed rails prior to installation, failed to review the risk and benefits with the resident or the resident representative and obtain informed consent prior to installation, and failed to ensure the bed's dimensions were appropriate for the resident's size and weight for three of 17 residents (Residents #4, #38 and #61). The facility census was 62. The facility did not have a policy for the use of bed rails. 1. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/17/22, showed: - Independent with bed mobility and transfers; - Diagnoses included: high blood pressure, neurogenic bladder, anxiety disorder, depression, manic depression, post traumatic stress disorder (PTSD), Paralytic gait (spastic gait, common in patients with cerebral palsy or multiple sclerosis, spastic gait is a way of walking 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 observations, interviews, and record review, the facility failed to ensure nursing staff had the appropriate competencies and training to provide nursing and related services to provide safe and effective transfers for two residents (Resident #61 and #8) of seventeen sampled residents. The facility census was 62. 1. Review of the facility policy for transfers dated 4/16/20 showed: - Administrator will designate a lift champion who is responsible for assuring the complete cooperation and compliance with our company's no lift policies and procedures. The champion must be a licensed healthcare provider. -A licensed healthcare provider will evaluate every resident at admission, readmission, and with any change in condition to establish if they have a need for a mechanical lift, which type of transfer, sling size, and number of team members required to use the lift for each resident. Evaluation is to be completed on PCC (point click care, facilities electronic records) after licensed healthcare provider does…

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 ensure they reported irregularities found by the consultant pharmacist to the attending physician in a timely manner for them to act on and failed to ensure the attending physician documented the identified irregularities had been reviewed and what action was taken. This affected one of 17 sampled residents (Resident #29). The facility census was 62. The facility did not provide a policy for ensuring the pharmacy consultant reports were communicated to the physician. 1. Review of Resident #29's quarterly MDS, dated [DATE], showed: - A BIMS of 13, indicating no cognitive impairment; - Independent with bed mobility, transferring between surfaces, and walking; supervision with toilet use; and limited staff assistance with dressing and personal hygiene; - Diagnoses included high blood pressure, thyroid disorder, arthritis, chronic obstructive pulmonary disease (COPD); - On a scheduled pain medication regimen; did not receive PRN pain medications in last…

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

Based on observation, record review and interview, the facility failed to ensure they administered residents' medications with an error rate not greater than 5 percent (%). The facility staff made 10 errors out of 26 opportunities for error with an error rate of 38.46%, which affected three residents (Resident #25, #36 and #38) of 17 sampled residents. The facility census was 62. Review of the facility's medication pass times showed staff should be passing medications at the following times in the morning : - 6:00 A.M.; - A.M. (6:00 to 10:00 A.M.); - 7:30 A.M.; - 9:30 A.M.; - 11:00 A.M. Review of the 2014 Medication Administration Competency Checklist, provide by the facility as their policy, showed: - Assessment: Checked accuracy and completeness of the medication administration record (MAR), clarified incomplete or unclear orders; - Crushed medications separately if patient/resident has difficulty swallowing, used pill crushing device properly, mixed medication with soft food; - Took medication to resident at correct time, applied six rights of medication administration; - Gave…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure staff discarded expired medications and discarded medications from discharged residents. This had the potential to affect all facility residents. The facility census was 62. 1. Review of the facility policy, dated 1/1/13, on storage of medications showed: - Staff should ensure medications are stored in an orderly manner. - Medications must have an expiration date on the label. - Staff must not retain medications longer than recommended by the manufacturer. - Once staff opened a medication, staff should follow manufacture's guidelines with respect for expiration for opened medications. - Staff must ensure that expired medications should be destroyed. - Staff must inspect medication storage areas for proper storage compliance on a regularly scheduled basis. Review of the Incruse Inhaler (used to treat lung conditions) package insert, dated June 2019 showed staff should discard the inhaler 60 days after opening. 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 ensure each resident received foods prepared in a way to conserve nutritive value, flavor, and appearance, and failed to serve foods in a safe and appetizing manner. This has the potential to affect all residents in the facility. The facility census was 62. Review of the facility's Meal Distribution policy, dated 9/2017, showed: -Meals are transported to the dining locations in a manner that ensures proper temperature maintenance, protects against contamination, and are delivered in a timely and accurate manner. -All meals will be assembled in accordance with the individual diet order, plan of care and preferences. -All food items will be transported promptly for appropriate temperature maintenance. -All foods that are transported to dining areas that are not adjacent to the kitchen will be covered. -The nursing staff will be responsible to verifying meal accuracy and the timely delivery of meals to residents. -For the point-of-service dining, the Dining Services department staff, under the supervision 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 prepare pureed foods in a way to conserve the nutritive value, flavor and appearance when staff did not follow the recipe for preparing pureed roast pork, mashed potatoes, mixed vegetables and bread with butter. The facility census was 62. Review of the facility Therapeutic Diets policy dated 9/2017 showed: -All residents have a diet order, including regular, therapeutic, and texture modification, that is prescribed by the attending physician, physician extender, or credentialed practitioner in accordance with applicable regulatory guidelines. -Therapeutic diet is defined as a diet ordered by a physician, or delegated registered or licensed dietitian, as part of the treatment for a disease or clinical condition. The purpose of a therapeutic diet is to eliminate or decrease specific nutrients in the diet or to increase specific nutrients in the diet or to provide food that a resident is able to eat (mechanically altered diet). -Mechanically altered diet means one in which the texture of the diet is altered.…

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 follow proper infection control practices when staff did not wash their hands during medication pass and when providing perineal care to prevent the spread of infection, which affected six of 17 sampled residents (Resident #6, #25, #29, #38, #61 and #63). The facility also failed to administer the Two-Step Tuberculin (TB) test appropriately, read, and document the results of the test in a timely manner, and failed to maintain record of conducting the staff's TB testing for seven of nine sampled employees. The facility's census was 62. Review of the facility's COVID-19 Education, Prevention and Response Guide, Handwashing/Hand Hygiene policy, dated March 2020, provided as the facility's policy on handwashing, showed the facility's policy considers hand hygiene the primary means to prevent spread of infections. All team members shall be trained and regularly in-serviced on the importance of hand hygiene in preventing transmission 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 staff treated all residents with dignity and respect when staff did not serve all residents seated at one table at the same time, leaving some residents to sit and watch their tablemates eat which affected all residents who eat in the main and assistive dining rooms and when staff did not talk with one of 17 sampled residents (Resident #8) when staff moved the resident's wheelchair abruptly two different times, causing the resident to flip backwards and then pitch forward abruptly. The facility census was 62. Review of the facility's Resident's Rights and Quality of Life policy, dated 5/1/12, showed it is the policy of Advocate that all residents have the right to a dignified existence, self-determination, and communication with an access to people and services inside and outside the facility. The list of resident rights did not include the right to be treated with dignity and respect. Review of the facility's posted meal times showed: - Breakfast: *Main dining room: 7:00 A.M. *Assisted 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 record review and interviews, the facility failed to ensure they considered the views of the resident group and acted promptly upon the grievances and recommendations of the group concerning issues of resident care and life in the facility and could not demonstrate their responses and rationale for those responses. The facility census was 62. Review of the facility's July 2018 policy titled Customer Concern (Grievance) policy showed the purpose of the the policy was to support each resident's right to voice concerns (grievances) and to ensure after receiving a concern, the center actively seeks a resolution and keeps the customer appropriately apprised of its progress toward resolution. The goal is to encourage open communication of customer concerns in an environment free from reprisal, retaliation or discrimination. We have a commitment to customer service and have systems in place to address concerns. Our Grievance Official is the Center Administrator. The Grievance Official's contact information including phone number and email address, will be readily available to any…

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 ensure they informed residents of their rights periodically during residents' stay both orally and in writing. The facility census was 62. Review of the facility's Resident's Rights and Quality of Life policy, dated 5/1/12, showed: - It is the policy of Advocate that all residents have the right to a dignified existence, self-determination and communication with an access to people and services inside and outside the facility. - The policy listed out all of the residents' rights. - The policy did not specifically indicate when these rights should be communicated with the residents. Observation on all days of the facility showed a framed poster listing the all the residents' rights hung on the wall at the start of the 200 hall. 20 of the facility's 62 residents resided on the 200 hall. This hall is located far away from the main portion of the facility and not a location that many residents see. During a group interview on 4/25/22 at 10:02 A.M., 21 residents in attendance said resident rights are only reviewed…

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

Based on record review and interview, the facility failed to ensure they conducted a complete criminal background check (CBC), and maintain copies of staff's Family Care Safety Registry (FCSR) letters, checks of the Employee Disqualification List (EDL), and nurse aide (NA) registry which included nine of nine sampled staff. The facility census was 62. Review of the facility's abuse and neglect policy, dated January 2019, showed: -To prohibit and prevent abuse, neglect, exploitation, misappropriation of resident property and to ensure reporting and investigation of alleged violations in accordance with Federal and State Laws. -Team Member-This designation equals employee/staff. -Each center will follow any and all state specific requirements. -Potential team members shall, at a minimum, have the following screening checks conducted: -Reference checks with previous employers and/or current employers -Appropriate licensing board or registry check -Drug testing per company policy -Criminal background check pursuant to company policy or state law -Office of Inspector General (OIG)…

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.

The facility failed to ensure they completed a thorough investigation into one of 17 sampled resident's (Resident #4) allegations of verbal abuse from a staff member when staff failed to interview the resident. The facility census was 62. Review of the facility's Abuse, Neglect, Misappropriation, Exploitation policy, dated January 2019, showed the purpose of the policy was to prohibit and prevent abuse, neglect, exploitation, misappropriation of resident property and to ensure reporting and investigation of alleged violations (to include injuries of unknown source, mistreatment, and involuntary seclusion) in accordance with Federal and State Laws. If actual violation or alleged violation occurs, the resident will be immediately assessed and removed from any potential harm (if applicable). The administrator, or designee, will over the center in conducting an internal investigation against any violation/alleged violation of abuse, neglect, exploitation, injury of unknown source, misappropriation of resident property, involuntary seclusion and report the results of the investigation 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 record review and interviews, the facility failed to ensure they maintained evidence of Level II screenings and any determinations of the need for a Preadmission Screening (PASRR) for two of 17 sampled residents Residents #6 and #9) who required Level II screenings. The facility census was 62. The facility did not provide a policy for completing Level I or Level II screenings and maintaining PASRR reports. 1. Review of Resident #6's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/2/21, showed: - admission date of 1/12/17; - Staff did indicated no the resident had not been evaluated by Level II PASRR and determined to have a serious mental illness and/or mental retardation or a related condition; did not indicate whether or not the resident had a serious mental illness, mental retardation or other related condition; - A Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive deficit; - A Resident Mood Interview score of 00, indicating no presence of depression; - No behaviors during 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 record review and interview, the facility failed to complete a discharge summary for one of two sampled closed residents (Resident #64). The facility census was 62. The facility did not provide a policy addressing discharge summaries. 1. Review of Resident #64's significant change Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 4/20/22 included the following: - The resident's Brief Interview for Mental Status (BIMS) score was three, indicating severe cognitive impairment. - Resident had physical and verbal behaviors directed at others. - Family participated in the assessment. - Resident did not plan to return to the community. Review of the nurses' notes dated 2/1/22 at 11:40 A.M. showed the facility transferred the resident to another facility. The resident went to the new facility's memory care unit. Review the of resident's medical record did not show a discharge summary. During an interview on 4/28/22 at 4:41 P.M., the facility administrator said the resident did not have a discharge summary. There was a discharge nurses' note…

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 they assisted one of 17 sampled residents (Resident #4) with performing activities of daily living (ADLs) when staff did not assist the resident when he/she wanted to take showers. Review of the Resident's Rights and Quality of Life policy, dated 5/1/12, showed it is the policy that all residents have the right to a dignified existence, self-determination and communication with an access to people and services inside and outside the facility. The policy did not address how to ensure residents' dignity was preserved, providing showers or ensuring residents had services provided in a timely manner or according to their preferences. 1. Review of Resident #4's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/17/22, showed: - A Brief Interview for Mental Status (BIMS) score of 15 which indicted no cognitive impairment; - Independent with most activities of daily living (ADLs) but needed one person physical assistance for bathing; impairment of both lower…

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 ensure residents did not receive unnecessary medications when staff failed to act on recommendations made by their consultant pharmacist to reduce medication doses and failed to ensure residents did not maintain as needed (PRN) narcotics beyond 14 days without reevaluation by the physician. This affected two of 17 sampled residents (Resident #8 and #29). The facility census was 62. The facility did not provide a policy for unnecessary medications. 1. Review of Resident #8's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/2/22, showed: - A Brief Interview for Mental Status (BIMS) of 10 indicating moderate cognitive impairment; - Needed extensive staff assistance with bed mobility, dressing and personal hygiene; total staff assistance with toilet use, moving on and off the nursing unit and transferring from surface to surface; - Diagnoses included: high blood pressure, diabetes, high…

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.