Creve Coeur Manor

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure third party liability (TPL) forms were completed within 30 days for the final accounting for residents who expired. This affected three residents who expired and had money in their accounts (Residents #104, #107 and #106). In addition, the facility failed to provide notification when the resident's trust account reached $200 less than the Supplemental Security Income (SSI) resource for four residents (Resident #7, #101, #102, #105). The facility held funds for 51 residents. The census was 74. Review of the facility Resident's Rights Policy, undated, showed the following: -Notice of certain balances: The facility must notify each resident that received Medicaid benefits: -When the amount in the resident's account reaches $200 less than the SSI resource limit for one person; -That, if the amount in the account, in addition to the value of the resident's other nonexempt resources, reaches the SSI resource limit for one person, the resident may lose…

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 and interview, the facility failed to maintain a clean, comfortable, and homelike environment for one of two floors, (the secured second floor) affecting the 30 residents of the second floor. Specifically, the facility failed to maintain an environment free of food splatters on the walls, missing ceiling tiles, functioning door handles, holes in bedroom walls, holes in bathroom walls, unclean surfaces of tables, bathroom tiles, and clean equipment for the ice container creating an unpleasant environment for the residents. Findings include: During an initial tour of the second floor secured unit on 11/11/24 from 10:45 AM to 12:45 PM, the following concerns were observed and discussed with the Administrator, Maintenance Director (MD), and the Housekeeping Supervisor on 11/14/24 beginning at 09:49 AM. The dining room: The four of four tables were marred, scarred, had peeling purple paint, and had uncleanable surfaces. The walls had spills that had run down and were dried. The ice chest was…

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

Based on interview and record review, the facility failed to ensure newly hired employees were screened to rule out the presence of a Federal Indicator, with the Certified Nurse Aide (CNA) Registry for seven staff members. A sample of 10 employees hired were reviewed. The facility hired at least 100 new employees since the last survey. The census was 74. Review of the facility's Abuse Prevention Program, dated 9/29/22, showed the following: -Procedures for Prevention -Pre-employment Screening of Potential Employees: This facility will not knowingly employ any individual convicted of resident abuse, neglect, or misappropriation of property. The facility will not knowingly employ any direct care staff convicted of any of the crimes listed in the State Healthcare Worker Background Check Act (unless waivered under the provision of the Act), or with findings of abuse listed on the State CNA Registry. The facility will not knowingly employ any licensed staff that have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding…

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 that diets provided were prepared and distributed as prescribed by the residents' physician for seven residents (R12, R43, R35, R171, R50, R4 and R26 ) out of 26 residents in the sample. The deficient practice has the potential for residents to lose weight. Findings include: 1. Review of R12's Face sheet in the electronic medical record (EMR) under the profile tab revealed diagnoses of Alzheimer's disease, dementia, psychotic disturbance, mood disturbance, cerebral infarction, type 2 diabetes without complications, abnormal weight loss and pressure ulcer, sacral region stage 2. Review of R12's physician orders in the EMR under the orders tab revealed an order for a pureed diet, power potatoes for lunch, cheesy eggs for breakfast, ice cream for snacks, health shakes at each meal, whole milk at breakfast and apple or cranberry juice for lunch and dinner. Observations on 11/11/24 at 12:30 PM; 11/12/24 at 8:30 AM; 11/12/24 at 12:45 PM…

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 tuberculosis (TB, a potentially serious infectious bacterial disease that mainly affects the lungs) policy when staff failed to complete a two step and the annual one step of the employee TB screening tests in a timely manner for a total of five employees. The census was 74. Review of the facility's Tuberculosis Policy, dated 2005, showed the following; -Tuberculosis (TB) Screening - Employees -It is the policy of this facility that all healthcare workers will undergo testing for tuberculosis upon hire. Initial testing will be completed using the two-step tuberculin skin test (TST) procedure. The first dose being administered within seven days after being employed and the second dose administered one to three weeks after the first test, if the first test is negative. 1. Review of Staff Member A's employee file, showed the following: -Hire date: 10/1/22; -No documentation of an annual one step. 2. Review of Staff Member B's employee file, showed the following: -Hire date: 7/18/23; -No documentation of an annual…

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 treat four of 26 sample residents (R) 14, R27, R171, and R220) with dignity and respect by failing to assist R171 with clean socks, to assist R220 to obtain clothing to wear instead of the hospital gown, and staff standing while assisting two (R27 and R14) residents to eat their meal. These failures created an undignified manor of care for the four residents. Findings include: 1. Review of R171's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed R171 was admitted [DATE] with diagnoses of dementia, schizoaffective disorder, bipolar disorder, borderline personality disorder, generalized anxiety, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 09/23/24 revealed a Brief Interview for Mental Status (BIMS) score of 00 out of 15 which indicated R171 was severely cognitively impaired. On 11/11/24 at 11:30 AM, R171 was observed wearing…

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 an alternative communication device for one resident (Resident (R) 35) of 26 sampled residents which failed to allow R35, who is non-verbal, a means to express himself. Findings include: Review of R35's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted on [DATE] with diagnoses of cerebral palsy, generalized anxiety disorder, mood disorder, conversion disorder with seizures or convulsions, dysphagia, and multiple sclerosis. Review of the quarterly Minimum Data Set (MDS) located in the EMR under the RAI tab, with an assessment reference date (ARD) of 09/17/24 revealed a Brief Interview for Mental Status (BIMS) score of zero out of 15 which indicated R35 was not able to answer the questions. R35 was identified to be non-verbal. Review of the Care Plan located under the RAI tab in the EMR dated 09/13/24 did not identify how the resident would communicate his wants 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 observation, interview, and record review, the facility failed to provide needed care in accordance with the resident's preferences for one of one resident (Resident (R)220) in the sample of 26 resident reviewed for skin care This failure had the potential to affect the physical, mental, and psychosocial health and well-being of the resident. Findings include: Review of R220's electronic medical record (EMR)Face sheet under the profile tab revealed R220 was admitted [DATE] with diagnosis acute kidney failure, generalized muscle weakness, and obesity. Review of R220's admission Minimum Data Set (MDS) in the EMR under the MDS tab with an assessment reference date (ARD) of 09/17/24 revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated R220 was cognitively Intact. Observation on 11/11/24 at 10:42 AM, revealed R220's feet and legs that appeared to be extremely dry with flaking skin onto the bedsheets. Interview with R220 at this time, she stated she would like to have…

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 a medication error rate of less than five percent. A total of three errors occurred out of 30 opportunities for error due to residents not receiving their medications on time for one resident (Residents (R)11) of six residents observed for medication administration. In addition, one of six residents (R41) received a medication that did not have a physician's order. The facility medication error rate was 6.67%. This failure had the potential to affect the accurate dosing of medication administered to the residents. Findings include: 1. During medication administration observation on 11/13/24 at 8:37AM, Licensed Practical Nurse (LPN)1, administered R1 Daily-Vite with folic acid tablet (MVI) one tablet. Review of R41's Physician Orders dated November 2024 in the electronic medical record (EMR) under the Orders tab indicated there was not a physician's order for the Daily Vite with folic acid medication. 2. During medication administration observation on 11/13/24 at 9:55AM, Certified Medical…

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, and interviews, the facility failed to ensure that the food residents received was at an appetizing temperature for one of three meals on one of four survey days. The deficient practice has the potential to affect all 69 residents who receive food from dietary. Findings include: Observation of food temperatures on the steam tabled revealed the regular diet pot roast was 174 Fahrenheit (F), the scalloped potatoes were 202 degrees F and the winter vegetables were 175 degrees F. The cart left the kitchen at 12:40 PM and arrived at the first floor at 12:42 PM. Lunch was scheduled to be served at 12:00 PM. Observation on 11/13/24 at 1:10PM of the test tray temperatures on the first floor kitchenette revealed using a facility thermometer pot roast 106 F. The pot roast tasted cool. Interview with the Dietary Manager (DM) at the time, he stated that the pot roast tasted cold to him. Interview with R11 at 1:15 PM on 11/13/24, after she had finished her meal, she stated the pot roast tasted cold. Review of R11's quarterly Minimum Data Set (MDS) with an Assessment…

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.

See the deficiency cited at Event K4Wl12. Based on observation, interview and record review, the facility failed to ensure one resident (Resident #1) was free from significant medication error by not obtaining the resident's prescribed narcotic in a timely manner. The sample size was three. The census 67. Review of the facility's Medication Order Policy, undated, showed: -This facility shall use uniform guidelines for the ordering of medication; -Medications should be administered only upon the signed order of a person lawfully authorized to prescribe; -Each medication order should be documented with the date, time and signature of the person receiving the order; -The order should be recorded on the physician order sheet, and the medication administration record (MAR); -Transcribe newly prescribed medication on the MAR or treatment record. Review of Resident #1's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/13/24, showed: -Severe cognitive impairment; -Diagnoses included heart failure, renal failure,…

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, comfortable, homelike environment by failing address plumbing and roofing issues that led to bulging, brown and rust-colored ceiling tiles in three residents' rooms (Resident #10, Resident #11, and Resident #12) and in the 100 hall shower room, that one resident used daily (Resident #1). The facility also failed to complete timely repairs and improvements to the walls in the main entrance lobby hallway leading to the main elevator. The sample size was 12. The census was 66. Review of the facility's Routine Maintenance policy, revision date, 8/16/22, showed maintenance staff is responsible to ensure that preventative, routine, maintenance is completed in compliance with applicable life safety standards and needs of the facility. Preventive and routine maintenance shall be completed according to the weekly, monthly, quarterly, semi-annual, and annual maintenance round forms. Review of the facility's Resident's Rights 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 observation, interview and record review, the facility failed to ensure one resident (Resident #1) was free from significant medication error by not obtaining the resident's prescribed narcotic in a timely manner. The sample size was three. The census 67. Review of the facility's Medication Order Policy, undated, showed: -This facility shall use uniform guidelines for the ordering of medication; -Medications should be administered only upon the signed order of a person lawfully authorized to prescribe; -Each medication order should be documented with the date, time and signature of the person receiving the order; -The order should be recorded on the physician order sheet, and the medication administration record (MAR); -Transcribe newly prescribed medication on the MAR or treatment record. Review of Resident #1's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/13/24, showed: -Severe cognitive impairment; -Diagnoses included heart failure, renal failure, dementia and seizures; -On a scheduled pain…

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

Based on interview and record review, the facility failed to designate a person to serve as the director of food and nutrition services with the appropriate certification, when a consultant Registered Dietician (RD) was not employed full-time with the facility. The census was 74. Review of the facility assessment, dated 5/22/23, showed the staffing plan included one contracted RD and one director of food/nutrition services. During an interview on 8/10/23 at 1:18 P.M., the Culinary Services Director said he worked as a cook in the facility for two years and has been employed in his current position for five months. He has a food certification. He was unable to specify the area of certification or provide a copy of the certification. The facility has a RD consultant with corporate who does not work with the facility full-time. During an interview on 8/11/23 at 7:40 A.M., the Administrator said the facility has a consultant RD who does not work for the facility on a full-time basis. The Culinary Service Director's certification and education information was requested. During an…

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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The facility failed to have a system for monitoring proper functioning of the dish machine to ensure proper sanitation. The facility failed to ensure foods were stored at the appropriate temperatures to prevent foodborne illness. The facility failed to ensure foods were prepared and distributed under sanitary conditions when dietary staff failed to exhibit appropriate hand hygiene while serving food and to have facial hair properly covered during food preparation. The facility failed to appropriately store and handle dishware, and to store bulk dry goods and canned goods in a manner to protect from cross contamination. These deficient practices had the potential to affect all residents who ate at the facility. The census was 74. 1. Observation on 8/8/23 at 9:51 A.M., showed Dietary Aide (DA) D placed a bin of dirty dishes into the dish machine. The external temperature gauge on the dish machine showed…

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 distribute interest (money paid regularly to depositors of money at a financial institution a particular rate) for residents who allowed the facility to manage their resident funds during the months of August 2022 through October 2022. In addition, the facility failed to ensure residents who held funds below $50.00 in the interest bearing bank account were credited interest earned on the account. (Residents #62, #16, #426, #28, #41, #276, #52, #427, #428, #9, #2, #26, #50, #429, #430 and #27). The census was 74. Review of the facility's Resident Trust Fund (RTF) policy, revised 2/2020, showed: -The Business Office Manager has the primary responsibility for ensuring that residents' funds are appropriate and legitimate; -Interest is to be posted once a month to resident accounts with an account balance of $50.00 or greater. 1. Review of the RTF bank statements for August 2022, September 2022 and October 2022, showed 0.00% interest credited to the RTF interest-bearing bank account. During an interview on 8/9/23 at 4:07 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.

Based on interview and record review, the facility failed to ensure general accounting principles were followed for an accurate accounting of all monies, by failing to research outstanding checks. This affected residents whose funds were managed by the facility. The census was 74. 1. Review of the facility provided September 2022 Check Listing Report dated 9/30/22, showed the following outstanding checks that had not cleared the bank as of 8/8/23. Check Number Date Amount 1043 08/17/2020 $3,250.11 1137 01/27/2021 $0.65 1311 08/04/2021 $3,483.10 1318 08/10/2021 $12.00 1389 11/08/2021 $136.00 1420 12/14/2021 $0.80 Review of the facility October 2022 Bank Reconciliation on 8/9/23, showed the checks written in 2020 and 2021 were not listed under the reconciled checks. During an interview on 08/09/23 at 4:07 P.M., the Business Office Manager (BOM) said he/she had not followed up on any of the old outstanding checks and did not know if there was a process in place. During an interview on 08/10/23 at 12:12 P.M., the Regional Business Office Manager (RBOM) said the facility went under new…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents had the right to reasonable access to the use of a telephone in a place where calls could be made without being overheard. The facility additionally failed to provide reasonable access to send and receive mail on the weekends. The facility census was 74. Review of the Resident's Handbook, undated, showed: A telephone for private calls is available for resident use 24 hours a day and each resident room is equipped for a telephone. Review of the Resident's admission Packet, undated, showed: A resident has the right to have a reasonable access to the private use of a phone. 1. Observation and interview on 8/8/23 at 7:25 A.M., showed, on the second floor, two white telephones in an unlocked room on a desk. One telephone was unplugged and one telephone was connected to a phone jack and did not have a dial tone. Certified Medicine Technician (CMT) J verified the phones in the room were designated for resident use only.…

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 provided residents a homelike environment by failing to maintain clean shower rooms on the 200 and 100 halls, out of three shower rooms observed. The resident sample was 18. The census was 74. 1. Review of the facility's House Keeping Duties list, showed the following: -One housekeeper per floor (1st and 2nd), pull all trash in all rooms and bathrooms, wipe bedside tables off, wipe furniture if needed, clean all bathrooms in rooms, clean all bathrooms in the hallways, clean shower rooms, clean dining rooms (sweep and mop) only, sweep and mop all rooms, pull trash in the serving areas, wipe doors front and back along with door knobs, wipe coffee and soda stains off walls, wipe food off walls, dust picture frames, put bags at the bottom of each trash can, clean mirrors in each room, pick up wet floor signs before leaving. 2. Observation of the 200 hall resident shower room on 8/7/23 at 5:18 A.M., showed the toilet full of urine and stool, and brown matter smeared on the walls next to the toilet and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized care plans, to address the specific needs of the residents for four of 18 sampled residents (Residents #4, #61,#70, and #277). The census was 74. 1. Review of Resident #4's Medical Record, showed: -Medical diagnoses included: Pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) to the left hip, abnormal weight loss, muscle weakness, depression, heart failure, and cerebral infarction (a blood clot in the brain affecting cognition); -The following care areas were noted on the quarterly Minimum Data Set, (MDS) a federally mandated assessment instrument completed by facility staff, dated 7/17/23: Cognitive loss, urinary incontinence, psychosocial wellbeing, and falls; -A readmission weight of 149 pounds (lbs) on 5/3/23; -A diet order placed on 7/14/23 at 2:10 P.M., for a regular diet with regular consistency liquids, and specifications…

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 required assistance with activities of daily living (ADLs) received personal care and showers in accordance with their needs and preferences (Residents #61, #40, #21 and #70). The sample was 18. The census was 74. Review of the facility's Bathing a Resident policy, revised July 2014, showed: -Policy: It is the policy of the company that residents will receive a shower/bath will be scheduled regularly and as needed (PRN); -Procedures included: -Check with the nurse to determine if special precautions need to be taken while showering or bathing the resident, e.g., cast, dressing, isolation precautions, toenails can be trimmed; -Assist the resident in showering/bathing if necessary; -Wash from head to feet, shampoo hair (if necessary), then wash perineal area; -Apply deodorant and lotion. If hair has been shampooed and will be dried in the resident's room, then towel dry hair and wrap in towel. Provide nail care if…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement an ongoing resident centered activity program that incorporates the residents' interests and maintains and/or improves residents' physical, mental and psychosocial well-being for three residents (Resident #61, Resident #5 and Resident #63). The sample was 18. The census was 74. Review of the facility's undated Activity Program policy, showed: -An ongoing program of activities is designed to meet the needs of each resident; -The activity program is designed to encourage restoration to self-care and maintenance of normal activity which is geared to the individual resident's needs; -Activities are scheduled daily and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup and critique of the program; -The activity program consists of individual, and small and large group activities which are designed to meet the needs and interests of each resident and includes, at a minimum: -Social…

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 the activities program was directed by a qualified professional. The census was 74. Review of the facility's undated Activities Program Staffing policy, showed: -The activity program is staffed with personnel who have appropriate training and experience to meet the needs and interests of each resident; -The activity program is under the direct supervision of a qualified professional who: - Is a qualified therapeutic specialist or an activities professional who is licensed or registered, if applicable, by the state in which the person is practicing; -Is eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body on or after October 1, 1990; -Or has two years' experience in a social or recreational program within the last five years; -Or is a qualified occupational therapist or occupation therapy assistant; -Or has completed a training course approved by the state. During an interview on 8/9/23 at 2:30 P.M., the Activities Director (AD) said 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 interview and record review, the facility failed to maintain an ongoing restorative nursing program (RNP) to ensure residents maintained their functional ability to the greatest extent possible (Residents #40, #16, #31, #35 and #57). The facility identified 20 residents as qualified for restorative therapy (RT) services. The census was 74. Review of the facility's Restorative Nursing policy, revised July 2014, showed: -Policy: It is the policy of the company to provide restorative nursing which promotes the resident's ability to live as independently and safely as possible. Restorative nursing focuses on achieving and maintaining the optimum level of physical, mental, and psychological function of the resident; -Procedure included: -Restorative nursing services are provided by Restorative Nursing Assistants, Certified Nursing Assistants (CNAs) and other staff trained in restorative techniques; -Restorative nursing is under nursing supervision; -Every resident who receives restorative nursing has a care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure proper gait belt usage and the care planning of gait belt usage to ensure resident safety for two of 18 sampled residents (Residents #57 and #35) and failed to complete a smoking assessment and supervision for one sampled resident (Resident #126). The census was 74. 1. Review of the facility's Gait Belt Use policy, revised July 2014, showed the following: -Policy: It is the policy that gait belts will be used when staff are transferring weight bearing residents or assisting them with walking for the safety of the resident or the employee; -Procedure: -Explain to the resident what is about to happen. The gait belt is placed around the resident's waist; -Fasten the gait belt snuggly, but not too tight. Be careful of tubes, wounds, or incisions; -When transferring the resident, use good body mechanics, bend knees, not back, reach under the resident's arms and hold the gait belt behind his/her back. Assist the resident to stand and…

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

Based on observation, interview and record review the facility failed to ensure the Director of Nursing (DON) did not serve as charge nurse when the facility's average daily census was greater than 60 residents. The facility census was 74. Review of the facility's resident census for the duration of the survey and licensure process, showed a daily census of 72 residents at the facility. Observation of the lunch meal on 8/9/23 at 5:41 P.M. showed a resident rested in bed with the dinner meal placed on his/her side table over the bed. The facility DON provided assistance to the resident with eating the meal of navy bean soup, a fruit cup, and a tuna sandwich. During interview on 8/11/23 at 9:03 A.M., the facility administrator and DON estimated the average daily census at the facility is around 70 residents. When asked how many days this week the DON was needed to work the floor in order to provide adequate staffing levels for resident care, the DON responded all of them. The DON said she typically works the 7:00 A.M. to 3:00 P.M. shift once or twice a week as the charge nurse and…

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

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored per acceptable standards of practice. These practices affected one out of three medication carts and one out of one medication room reviewed. The census was 74. 1. Review of the facility's Medication Labels policy, undated, showed: -Labels are permanently affixed to the outside of the prescription container; -Each prescription medication label or package includes: -The resident's name; -Specific directions for use, including route of administration; -Medication name; -Strength of medication; -Prescribers name; -Date dispensed; -Quantity of medication; -Beyond use (or expiration) date of medication on the package. Review of the facility's Controlled Substance policy, revised July/2014, showed: -Controlled substances must be stored in the mediation room in a locked container or in a mediation care in a locked box, separate from containers for any non-controlled medications. 2. Review of the manufacturer's instructions for Advair inhaler (a medication used to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, staff failed to maintain resident dignity by speaking to and assisting one resident (Resident # 37) during mealtime in a disrespectful manner. Additionally, the facility failed to ensure one resident came to the dining room in clean and odor free clothing (Resident #61) and one resident wore proper undergarments to enhance his/her dignity (Resident #70). The census was 74. Review of the Resident Rights admission Packet, undated, showed: The facility shall care for its residents in a manner and in an environment that promotes maintenance or enhancement of each resident's quality of life. 1. Review of Resident #37's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/17/23, showed: -The resident is rarely or never understood; -No rejection of care or behaviors; -Required supervision with eating. Review of the resident's care plan, in use at the time of the survey, showed: -Focus: Behavioral symptoms;…

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 reasonable accommodations of individual needs and preferences by failing to ensure Resident #57 had assistive devices while eating. The sample was 18. The census was 74. Review of Resident #57's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/7/23, showed the following: -Diagnoses of legal blindness, chronic kidney disease and hypertension; Cognition not listed; -Supervision/touch assistance needed when eating. Review of the resident's care plan, dated 2/7/23, showed the following: -Problem: resident is on a mechanical soft diet. He/She has special devices needed during meals: divided plate, dycem (a non slip material used under a resident's plate to avoid plate movement), and food in bowls; -Goal: Resident to follow diet as much as possible x 90 days; -Approach: Diet as ordered: mechanical soft. Resident prefers to eat meals in room/eat meals in dining room Observation on 8/8/23 at 7:53 A.M., showed the resident ate cereal with his/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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to assure that each resident receives an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas and are knowledgeable about the resident's status, needs, strengths, and areas of decline. Inaccurate assessments occurred for two of three closed record sampled residents (Residents #73 and #74). The census was 74. 1. Review of Resident #73's discharge Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) assessment, dated [DATE], showed: -The resident discharged [DATE]; -discharged to an acute care hospital. Review of the resident's electronic physician order sheet (ePOS), showed an order dated [DATE], for discharge to a different long term care facility with current medications. Review of the resident's progress notes, showed: -On [DATE] at 1:23 P.M., discharge order and has been accepted to a different long term care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure care provided met acceptable standards of nursing practice. This included medication administration incongruent with the medical record for one resident and nutritional tube feedings not provided as ordered for one resident (Residents #1 and #55). The facility census was 74. Review of the facility's Monitoring of Medication Administration policy, undated, showed: -To administer all medication safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms, and help in diagnosis; -Read and follow any special instructions written on labels. 1. Review of Resident #1's electronic physician order sheet (ePOS), showed: -An order dated 11/20/17, for Melatonin (natural sleep supplement) 3 milligram (mg). One table per gastrostomy tube (g-tube, a tube placed through the abdomen into the stomach to provide nutrition, hydration and medication) at bed time for sleep; -An order dated 2/07/23, for acetaminophen…

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 diets and supplements as ordered to ensure residents maintained acceptable nutritional status for two residents with weight loss, one of which was significant (Residents #4 and #40). The facility also failed to appropriately monitor meal intake and develop and/or implement resident specific-interventions to address weight loss. The sample was 18. The census was 74. Review of the facility's Nutritional Assessments policy, revised January 2012, showed: -Policy: All residents who experience significant or undesirable weight loss shall be assessed for nutritional status and required intervention by the Registered, Licensed Dietitian (RDLD). A course of action increasing calories shall be implemented unless the weight loss is deemed desirable and necessary for medical status. If increasing calories are required, a request for supplementation shall be made by the RDLD to the physician through nursing. The order shall be 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.

Based on observation, interview and record review, the facility failed to establish a system of records of receipt for all controlled drugs in sufficient detail to enable an accurate reconciliation for one out of one medication room reviewed. The census was 74. Review of the facility's Controlled Substance policy, revised July 2014, showed: -Controlled substance must be counted upon delivery. The nurse receiving the order, along with the person delivering the medication order, must count the controlled substances together; both individuals must sign the designated narcotic record; -Controlled substances must be stored in the mediation room in a locked container or in a mediation cart in a locked box, separate from containers for any non-controlled medications. Observation and interview on 8/8/23 at 9:07 A.M., in the second floor locked medication room, showed 59 vials of lorazepam (a medication to treat anxiety) 2 milligrams (mg) per milliliter (ml) located in an unlocked refrigerator. The packaging on the medication bags that the lorazepam was being stored showed 60 vials 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 interview and record review, the facility failed to ensure as needed (PRN) psychotropic medications were re-evaluated after 14 days for two residents (Resident #50 and Resident #61). The sample size was 18. The census was 74. Review of the facility's Psychotropic Medication Use policy, revised December 2018, showed: -Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record and PRN orders for psychotropic drugs are limited to 14 days. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record. 1. Review of Resident #50's Quarterly Minimum Data set (MDS, a federally mandated assessment instrument completed by facility staff), dated 8/1/23, showed: -Cognitively intact; -No behaviors; -Rejection of care one to three days; -Diagnoses…

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 administer medications with a less than five percent medication error rate. Out of 25 opportunities for error, two errors occurred, resulting in an 8% medication error rate (Resident #1). The sample size was 25. The census was 74. Review of the facility's undated Monitoring of Medication Administration policy, showed: -Based on the facility medication administration policy designated nursing staff to administer all medication safely and appropriately to aid resident to overcome illness, relieve and prevent symptoms, and help in diagnosis; -Review the resident's Medication Administration Record (MAR). Read each order entirely; -If there is any discrepancy between the MAR and the label, check physician orders before administering medication; -If the label is wrong it is the responsibility of the nurse to apply a Direction Change sticker to the medication label; -If the medication is discontinued or outdated, removed medication for proper disposal. Review of Resident #1's quarterly Minimum Data Set (MDS), 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, interview, and record review, the facility failed to maintain and follow recipes to ensure adequate nutritive value of fortified foods (super cereal and power potatoes) used to assist residents in maintaining acceptable nutritional status (Residents #40 and #4). The census was 74. 1. Review of Resident #40's medical record, showed diagnoses included high blood pressure, high cholesterol, low potassium, anemia (blood disorder), multiple sclerosis (nervous system disease affecting the brain and spinal cord), anxiety, and depression. Review of the resident's electronic Physician Order Sheet (ePOS), showed an order, dated 10/19/22, for regular diet. Special instructions included super cereal for breakfast and power potatoes for lunch. Review of the resident's nurse practitioner note, dated 6/14/23, showed chief complaint of follow-up related to weight loss. Weight is stable. Weight is 177.2 lbs. Abnormal weight loss. Continue with power potatoes, super cereal, health shakes three times a day, and larger portions of meals. Review of the resident's care plan, in use…

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 arrangements were made for pain management services outside of the facility for two residents prescribed narcotic pain medication (Residents #16 and #126). The sample was 18. The census was 74. 1. Review of Resident #16's medical record, showed diagnoses included pain in left knee and anxiety. Review of the resident's electronic Physician Order Sheet (ePOS), showed an order, dated 5/12/23, for tramadol (pain medication) 50 milligrams (mg), three times a day as needed (PRN). Review of the resident's June 2023 electronic Medication Administration Record (eMAR), showed; -Tramadol administered 46 times; -No tramadol documented as administered after 6/24/23. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/28/23, showed: -Cognitively intact; -On a scheduled pain medication regimen; -Diagnoses included osteoarthritis. Review of the resident's care plan, in use 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 observation, interview and record review, the facility failed to ensure medical records were accurately documented in accordance with acceptable professional standards of practice when staff failed to document skin assessments for one resident with a blister on his/her left heel (Resident #5). Staff documented nutritional supplements as administered for two residents (Residents #40 and #4) when the supplements were not provided, and staff failed to accurately document meal intake in accordance with physician orders. The sample was 18. The census was 74. Review of the facility's Charting policy, revised February 2012, showed: -Policy: It is the policy of the company that all services provided to the residents, or any changes in the resident's condition, shall be recorded in the resident's medical record; -Procedures included: All observations, medications given, services performed, etc., must be recorded in the resident's chart. 1. Review of Resident #5's quarterly Minimum Data Set (MDS), a federally…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to complete a baseline care plan within 48 hours of admission and failed to document the baseline care plan was reviewed with the resident or responsible party for two residents (Residents #77, #241) out of 24 sampled residents. The facility census was 99. The administrator said the facility does not have a policy directing staff on completion of the baseline care plan. 1. Review of Resident #77's Minimum Data Set (MDS), a federally mandated assessment tool, dated 1/3/20, showed staff assessed the resident as follows: -admission date of 1/3/20; -Moderate cognitive impairment; -Total physical dependence of one staff for transfers, dressing, toileting, personal hygiene, and bathing; -Extensive physical assistance of one staff for locomotion; -Limited physical assistance of one staff for eating; -Limited range of motion of the upper extremity on one side; -Always incontinent of bladder, frequently incontinent of bowel; -Occasional complaint of pain rated…

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, facility staff failed to ensure they observed three residents (Residents #19, #28 and #44) take their medications, failed to ensure two residents (Residents #28 and #47) did not have inhalers left at their bedsides, and failed to apply the appropriate treatment to one resident's (Resident #53) pressure ulcer. The facility census was 99. 1. Observation on 3/3/20 at 4:48 P.M., showed Certified Medication Technician (CMT) K administered to Resident #28, the following medications: -Docusate sodium (laxative) 100 milligrams (mg); -Eliquis (anticoagulant) 100 mg tablet; -Tamsulosin (treats symptoms of enlarged prostate) 0.4 mg capsule. The CMT handed the resident a cup of the three medications, then left the resident's room and did not observe the resident take the medications. 2. Observation on 3/3/20 at 5:05 P.M., showed CMT K prepared medications for Resident #19 in the hallway outside the resident's room. The CMT popped Metformin 1000 mg, one tablet into a cup and handed the cup to Resident #18 (Resident #19's spouse), and allowed…

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 the Director of Nursing (DON) served as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents. The facility census was 99. 1. Review of the Facility Assessment, dated June 2019, showed it did not address the DON serving as a charge nurse. Review of the facility's Daily Assignments schedule, dated 3/1/20 - 3/6/20, showed the DON was assigned to work as a charge nurse on the day shift on Monday, 3/2/20, and on on Tuesday 3/3/20. During an interview, the DON said he/she had been employed at the facility for two weeks. The DON said, in addition to occasionally working as the charge nurse for a shift, the DON covers the floor when a nurse must leave early in the morning or come in late in the evening. During an interview., the administrator said the DON often works on the floor as a charge nurse, including on 3/2/20 and 3/3/20. He/She was not aware the DON could not work as a charge nurse if the facility had 60 or more residents.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure the call light bulbs illuminated in the hallway for resident rooms and resident bathrooms when the call light button was activated. This practice potentially affected all residents in the facility. The facility census was 99 residents. 1. Observations with the Maintenance supervisor on 3/06/20, showed: -At 8:56 A.M., room [ROOM NUMBER], the call light to the hallway was burnt out. -At 10:29 AM., the call light bulb on the ground level and used by residents when in activities had been disabled and was not in working condition. During an interview on 3/06/20 at 10:29 A.M., the maintenance director said he did not know about these, because he had not been told by the staff there was a problem.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility staff failed to ensure two dependent residents (Residents #53 and #72) had their call lights within reach to allow them to call when they required staff assistance. The facility census was 99. 1. Review of Resident #72's most recent Minimum Data Set (MDS), a federally mandated assessment tool, dated 1/14/20, showed the following staff assessment: -Understands others; -Usually understood; -Dependence on staff assistance for completion of his/her activities of daily living (ADLs). Review of the resident's comprehensive care plan for the area of ADL functional status, not dated, showed the resident needs assistance from one staff member. Review of the resident's care card showed the following: -Staff are directed to assist x 1 with all ADLs; -The resident self-propels in a wheelchair; -The resident is at risk for falls; -The resident is incontinent of bowel and bladder. Observation on 3/2/20 at 4:56 P.M. showed the resident sat in his/her wheelchair with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to ensure one resident's (Resident #77) physician's orders for his/her code status matched the resident's advance directive wishes and failed to ensure two residents' (Residents #65 and #307) current physician's orders listed the resident's code status. The facility census was 99. 1. Review of Resident #65's code status form in front of the medical record, dated [DATE], showed the resident wished to be a full code. Review of the resident's physician's order sheet (POS) dated [DATE]-[DATE] showed no code status listed on the resident's current physician's orders. 2. Review of Resident #77's Code Status Form in his/her medical record showed it is his/her choice to be a Full Code (Cardio Pulmonary Resuscitation (CPR) would be performed if the resident's heart and/or breathing stopped). Review of the POS, dated [DATE] - [DATE], showed the resident did not have an order for code status. 3. Review of Resident #307's Code Status Form in front of the medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to revise, review and/or update the comprehensive care plan for three residents (Residents #31, #44, and #46). Review of the facility's undated Comprehensive Care Plan Development policy and procedure, showed it is the policy of the facility to complete a comprehensive care plan for each resident requiring a Minimum Data Set (MDS) assessment and care area assessment (CAA) completion. 1) The care plan is based on the CAA process, which is required for Omnibus Budget Reconciliation Act (OBRA)-required comprehensive assessments. 2) After completing the MDS and CAA portions of the comprehensive assessment, the interdisciplinary team must evaluate the information gained to develop a care plan that addresses those findings in the context of the resident's strengths, problems, and needs. 3) A new care plan does not need to be developed after each annual assessment or significant change assessment, but the MDS and CAAs should be assessed for the need to modify…

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, facility staff failed to provide adequate and appropriate perineal cleansing for two dependent residents (Residents #23 and #46) and failed to ensure good grooming for one resident's (Resident #72) fingernails. The facility census was 99. 1. Review of Resident #23's most recent MDS, dated [DATE], showed the following staff assessment: - Required extensive assistance from staff for dressing, toileting and personal hygiene; - Always incontinent of bladder; - Frequently incontinent of bowel; - Diagnosed with a urinary tract infection (UTI). Review of the resident's care plan, with multiple dates, showed the following: - The resident was at risk for pressure ulcers. Staff were directed to manage moisture (skin and incontinence management); - The resident was reluctant to perform personal hygiene without assistance. Staff were directed to assist as needed. Observation on 3/3/20 at 9:50 A.M., showed certified nurse aide (CNA) B provided care for the resident while 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 and record review, facility staff failed to implement new interventions for one resident (Resident #66) after he/she resident had multiple falls. In addition, staff failed to follow the facility policy for falls. The facility census was 99. Review of the facility's Tracking Record for Improving Patient Safety (TRIPS), undated, showed the following: - It is the policy of this facility that a TRIPS form is completed on every resident experiencing a fall; - After evaluating and treating the resident immediately, the nurse should investigate the circumstances of the falls and look at all possible causes. All licensed nurses will be trained in the immediate fall response; - The Falls Nurse Coordinator will use the data recorded on the TRIPS form to identify trends related to types of falls. Such details include location, time and activity; - The nurse is still required to complete a narrative nurses note. 1. Review of Resident #66's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 1/14/20, showed staff assessed the resident as follows: -…

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, facility staff failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for one resident (Resident #241), when they did not evaluate the resident's usual patterns of behavior, did not document changes in the resident's behavior, did not document they informed the physician about changes in a resident's behavior, and did not implement individualized non-pharmacological interventions to address the resident's behavioral symptoms. The facility census was 99. Review of the facility's Behavior Management Policy, undated, showed the following: - It is the policy of this facility to identify behavioral symptoms using appropriate screening tools, manage behavioral symptoms appropriately and comply with regulatory requirements related to the use of medications to manage behavioral changes. Behavior can be a way for an individual in distress to communicate unmet needs, indicate discomfort or express thoughts that cannot be articulated; -…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility staff failed to ensure one resident (Resident #16) was not given psychotropic medication unless necessary, when they started the resident on Seroquel (an antipsychotic), after the hospital directed this medication be discontinued, increased the dose of this medication from 12.5 mg to 50 mg without any indications to do so, and did not address a pharmacist's recommendation to clarify the dose of the Seroquel. Additionally, the facility staff failed to perform Gradual Dose Reductions (GDRs) on psychotropic medications in accordance with Centers for Medicare & Medicaid Services (CMS) guidelines for one resident (Resident #78). The facility census was 99. Review of the facility's Antipsychotic Medication Use Policy, dated 2015, showed the facility will attempt to taper psychotropic medication use in at least two separate quarters with at least one month between attempts, unless clinically contraindicated, during the first year. This will occur for both…

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, facility staff failed to ensure they administered medications with an error rate of less than five percent. Facility staff made two errors of a total of 32 medications passed, yielding an error rate of 6.25%. The facility census was 99. 1. Review of Resident #18's physician's order sheet (POS) dated 3/1/20-3/31/20, showed a physician's order for Meloxicam (a non-steroidal anti-inflammatory medication used to treat arthritis) tablet, give one by mouth twice daily with food. Review of potential side effects of Meloxicam include upset stomach, nausea, vomiting, heartburn, diarrhea constipation, and serious gastrointestinal effects including bleeding, ulceration and perforation of the stomach or intestines. Observation on 3/3/20 at 5:07 P.M., showed Certified Medication Technician (CMT) K administered to the resident, his/her Meloxicam tablet in the resident's room without any food. Review of the facility's dining times showed dinner was served starting at 5:30 P.M. During an interview on 3/6/20 at 5:30 P.M., the administrator and…

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

Based on observation and interview, facility staff failed to label and store medications in an appropriate manner when they failed to date insulin and multi-use vials on the date the vials were opened, failed to ensure medication carts were free of loose pills, and failed to discard expired medications. The facility census was 99. 1. Observation on 3/5/20 at 10:17 A.M., of the medication room on the first floor of the facility showed the following: In an upper storage cabinet: -A 100 count box of bisacodyl suppositories (laxative) with an expiration date of 9/19; -A four ounce bottle of Ultra tuss cough suppressant expectorant with an expiration date of 9/19; -A 100 count box of mucus relief guaifenesin (reduces chest congestion) 400 mg, with an expiration date of 12/19; -A one-half ounce bottle of ear drops earwax removal aide with an expiration date of 10/19; -A 16 ounce bottle of iron supplement elixir ferrous sulfate 220 mg with an expiration date of 1/20. In a medication refrigerator: -A bottle of Brisk lemonade stored in the freezer portion of the refrigerator; -An opened vial…

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, facility staff failed to adequately clean and disinfect multi-use blood glucose meters between resident use and failed to clean vials of insulin prior to removing insulin for injection for one resident (Resident #19). The facility census was 99. 1. Observation on 3/3/20 at 4:57 P.M., showed Certified Medication Technician (CMT) K obtained the multi-use blood glucose meter from a container in the top drawer of the CMT medication cart. The CMT did not clean the machine before he/she used the machine to check Resident #19's fingerstick blood glucose level. After obtaining the blood glucose result, the CMT placed the blood glucose meter back into the top drawer of the medication cart without cleaning the meter. The CMT then obtained the resident's Levimir insulin and the resident's Novolog insulin bottles from a container in the top drawer of the medication cart which held multiple other residents' insulin bottles, and drew up the doses of insulin without first cleaning the tops of the vials. Observation on 3/5/20 at 4:10 P.M., showed CMT D obtained…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to maintain and follow policies and procedures for immunization of residents against pneumococcal disease as required. The facility staff failed to provide and document provision of pertinent information regarding the pneumococcal vaccine including the benefits and potential side effects of the pneumococcal vaccine for six residents (Residents #1, #6, #8, #21, #77, and #88). The facility also failed to assess and vaccinate eligible residents with the pneumococcal vaccine with recommended doses of pneumococcal vaccine as indicated by the Centers for Disease Control (CDC) guidelines. The facility census was 99. Review of the US Department of Health and Human Services CDC Pneumococcal Vaccine Timing for Adults dated 11/30/15 showed the following: -Two pneumococcal vaccines were recommended for adults: 13-valent pneumococcal conjugate vaccine (PCV13, PREVNAR13) and 23-valent pneumococcal polysaccharide vaccine (PPSV23, Pneumovax 23); -One dose of PCV 13 was…

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