Delhaven Manor

Based on observation, interview and record review, the facility failed to ensure staff transporting residents in the company vehicle held the proper driver license in accordance with Missouri state regulations, for one of one days of observation. This had the ability to affect all residents who were transported in the facility vehicles. The census was 61. Review of the Missouri State Driver's Guide, revised August 2023, showed the following: -A Class F license is Missouri's basic driver license and is needed to operate any motor vehicle other than one requiring the driver to have a Class A, B, C or E license. -Anyone who transports 14 or fewer passengers for pay or as part of his/her job must have a class E license; -Anyone who regularly operates a motor vehicle for his or her employment, that belongs to another person and is designed to carry freight and merchandise, must also have a Class E license. Review of the facility's transportation escort job description, showed the following: -Duties: Escort patients to medical appointments and other areas of the facility; -Requirements:…

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 employ a qualified social worker on a full-time basis. The facility was licensed and certified for 156 residents. The current census was 61. Review of the facility's license and certification records, showed the facility licensed for 156 beds, of which 156 beds were certified for Medicaid and Medicare. Review of the facility's Social Worker's job description, showed the following: -The primary purpose of this position is to assist in planning, organizing, implementing, evaluating, and directing the overall operation of the facility's Social Services Department in accordance with current federal, state, and local standards, guidelines and regulations, our established policies and procedures, and as may be directed by the Director of Social Services and/or Administrator, to assure the medically related emotional and social needs of the resident are met/maintained on an individual basis; -Experience: Must have, as a minimum, a bachelor's degree in social work or a bachelor's degree in a human services field including but not…

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 establish a system of record for all controlled drugs with sufficient detail to enable an accurate reconciliation for four out of four narcotic count books reviewed. This had the potential to affect all residents with controlled substance orders. The census was 64. Review of the facility's Controlled Substances policy, revised November 2022, showed: -Dispensing and Reconciling Controlled Substances: -Controlled substance inventory if monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up; -Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count; -The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services. 1. Review of the controlled drug count sheets for the 1st Certified Medication Technician (CMT) cart, dated 5/1/24 through 5/31/24, showed: -No outgoing staff…

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 one resident's right to be free from physical abuse was not violated (Resident #4) when a resident (Resident #5) hit the other resident in the face. The sample was 5. The census was 62. Review of the facility's Residents Rights policy, revised 2/2021, showed: -Be free from abuse, neglect, misappropriation of property, and exploitation; -Includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. Review of the facility's abuse and investigation and reporting policy, revised 7/2017, showed: -All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigation will also be reported; -Policy interpretation and implementation: -The Administrator will…

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 services provided met professional standards of practice by not following the physician orders for two residents (Resident #1 and #4). The facility failed to administer all medication as ordered and did not document the reasons for the omissions. The sample was 5. The census was 62. Review of the facility's Medication orders policy revised November 2014, showed; Policy: The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. -Each resident must be under the care of a Licensed physician authorized to practice medicine in this state and must be seen by the physician at least every sixty (60) days; -A current list of orders must be maintained in the clinical record of each resident; -Orders must be written and maintained in chronological order. Review of the facility's administering medications policy, revised 2019, showed: Policy: Medications are administered in a safe and safe 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 interview and record review, the facility failed to ensure services provided met professional standards of practice by not following the physician orders for Resident #4. The facility failed to administer his/her medication and did not document the reasons and notification to the physician. The sample was 5. The census was 62. Review of the facility's Medication orders policy, revised November 2014, showed; -Policy: The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders; -Each resident must be under the care of a Licensed physician authorized to practice medicine in this state and must be seen by the physician at least every sixty (60) days; -A current list of orders must be maintained in the clinical record of each resident; -Orders must be written and maintained in chronological order. Review of the facility's administering medications policy, revised 2019, showed: -Policy: Medications are administered in a safe and safe and timely manner, and as prescribed; -Staffing schedules are arranged to ensure that…

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 accommodation of needs and preferences for one resident when staff failed to assist him/her out of bed when he/she requested (Resident #1). The sample size was 3.The census was 60. Review of the facility's Activities of Daily Living (ADLs) Supporting policy, last reviewed by the facility 2/6/24, showed: -Policy Statement: Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living; -Policy Interpretation and Implementation: -Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: -Mobility (transfer and ambulation, including walking); -Care and services to prevent and/or minimize functional decline will include appropriate pain management, as well as treatment for depression and symptoms of depression; -Interventions to…

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

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive care plan to address the resident's specific needs, which included fall interventions. The staff failed to conduct fall investigations to determine fall causes and interventions for 3 of 3 falls. In addition, the faclity failed to revise the resident's care plan to address his/her change in mood and access to socialization (Resident #1). The sample size was 3. The census was 60. Review of the facility's Care Plans, Comprehensive Person-Centered, revised 3/2022, showed: -Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; -Policy Interpretation and Implementation: -The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident; -The care plan interventions are derived…

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 identify potential safety hazards for one resident's environment, who staff assessed as being unable to move while in bed, when the staff left the bed remote control under the resident's back (Resident #1). The resident's back applied pressure to the bed remote control and caused it to elevate to the highest position. This resulted in a one centimeter laceration of the head and a C-2 (a break in the second vertebra of the neck) neck fracture. In the two weeks following this fall with injury, the resident had two additional falls. The facility failed to investigate and implement additional safety interventions after each fall. The sample size was 7. The census was 60. Review of the facility's Falls-Clinical Protocol, revised 3/2018, showed: -Assessment and recognition: -The physician will help identify individuals with a history of falls and risk factors for falling; -The staff and physician will document in the medical record a history of one or more recent falls; -While many falls are isolated individual…

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 services to promote one of seven sampled resident's highest possible level of well-being, to assure the emotional and social needs of the resident were met/maintained. The facility also failed to address the resident's mental and psychosocial needs thoroughly, which negatively impacted him/her, causing feelings of isolation and sadness (Resident #1). The sample was 7. The census was 60. Review of the facility's Social Service Designee documentation policy, dated 2003, showed: -The primary purpose of your job position is to assist in planning, developing, organizing, implementing, evaluating, and directing our facility's social service programs in accordance with current existing federal, state, and local standards, as well as our established policies and procedures, to assure that the medically related emotional and social needs of the resident are met/maintained on an individual basis; -Administrative functions: -Record and maintain regular social service progress notes indicating response to 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.

See the deficiency cited at event ID RFBY12. Based on interview and record review, the facility failed to use the services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week. The staffing sheets were reviewed for the month of August, 2023 and no RN was scheduled for the weekend. The census was 60. Review of the facility's August 2023 staff schedule, reviewed on 8/25/23, showed: -No staff listed under the job description of RN supervisor; -Every shift identified the nurses working as Licensed Practical Nurses (LPNs); -No RNs scheduled; -Weekend dates with no RN coverage included 8/5, 8/6, 8/12, 8/13, 8/19, and 8/20/23. During an interview on 8/25/23 at 10:23 A.M., the Director of Nursing (DON) said she began employment at the facility in July 2023. He/She typically works Monday through Friday. The facility does not have an RN scheduled on the weekends. During an interview on 8/25/23 at 10:32 A.M., the staffing coordinator said she will refer questions about RN staffing to the DON. During an interview on 8/25/23 at P.M., the Administrator said they do not…

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 use the services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week. The staffing sheets were reviewed for the month of August, 2023 and no RN was scheduled for the weekend. The census was 60. Review of the facility's August 2023 staff schedule, reviewed on 8/25/23, showed: -No staff listed under the job description of RN supervisor; -Every shift identified the nurses working as Licensed Practical Nurses (LPNs); -No RNs scheduled; -Weekend dates with no RN coverage included 8/5, 8/6, 8/12, 8/13, 8/19, and 8/20/23. During an interview on 8/25/23 at 10:23 A.M., the Director of Nursing (DON) said she began employment at the facility in July 2023. He/She typically works Monday through Friday. The facility does not have an RN scheduled on the weekends. During an interview on 8/25/23 at 10:32 A.M., the staffing coordinator said she will refer questions about RN staffing to the DON. During an interview on 8/25/23 at P.M., the Administrator said they do not use agency staff. The facility has job…

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 2. A review of Resident #110's Face Sheet revealed the facility admitted the resident on [DATE] with diagnoses that included chronic obstructive pulmonary disease, congestive heart failure, and diabetes mellitus. A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #110 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The MDS indicated Resident #110 was independent with bed mobility, transfers, and locomotion and required extensive assistance from staff with toilet use and personal hygiene. The MDS indicated Resident #110 was always continent of bladder and always incontinent of bowel. According to the MDS, Resident #110 had almost constant pain that the resident described as severe; the resident received a scheduled pain medication regimen. The MDS indicated that Resident #110 was at risk of developing pressure ulcers/injuries. A review of Resident #110's Care Plan, revealed…

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 resident and staff interviews and record reviews, it was determined the facility failed to provide quarterly financial statements to 2 (Resident #2 and Resident #24) of 24 residents who had resident trust accounts with the facility. The facility census was 57. Findings included: 1. A review of a quarterly Minimum Data Sheet (MDS), with an Assessment Reference Date (ARD) of 04/29/2023, indicated the facility readmitted Resident #2 on 08/06/2019 with active diagnoses that included hypertension, diabetes, and depression. The MDS also indicated Resident #2 was cognitively intact, with a score of 15 on the Brief Interview for Mental Status (BIMS). During an interview on 06/26/2023 at 11:00 AM, Resident #2 stated they did not receive a quarterly statement for their resident trust account. A review of an Open Balance Report, dated 06/28/2023, revealed a list of residents who had trust accounts with the facility. Resident #2 was listed on the report, indicating they had a trust account with the facility. During an interview on 06/29/2023 at 4:50 PM, the Administrator stated that…

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, record review, and facility document and policy review, the facility failed to ensure Level 1 Preadmission Screening and Resident Reviews (PASARRs) were accurately completed upon admission for 2 (Resident #8 and Resident #54) of 3 residents reviewed for PASARR. Specifically, the facility failed to ensure Resident #8 had a Level I PASARR completed prior to admission and failed to ensure Resident #54's Level I PASARR was accurate and included mental illness diagnoses upon admission. The facility census was 57. Finding included: Review of a facility policy titled, admission Criteria, revised in March 2019, indicated, Our facility admits only residents whose medical and nursing care needs can be met. Further review of the policy revealed the objectives of the facility's admission criteria were to, e. assure that the facility receives appropriate medical and financial records prior to or upon the resident's admission. Although requested, a policy specific to PASARR was not provided. 1. A review of Resident #8's Face Sheet revealed the facility admitted the resident on…

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

Based on observations, interviews, record review, and policy review, it was determined that the facility failed to provide services to residents who were unable to carry out activities of daily living (ADL) necessary to maintain good grooming and personal hygiene for 2 (Resident #23 and Resident #308) of 17 sampled residents reviewed for assistance with ADL care. Specifically, Resident #23 and Resident #308 had fingernails that were long with dirty substances underneath the nails. The facility census was 57. Findings included: Review of a facility policy titled, Activities of Daily Living (ADLs), Supporting, revised 03/2018, indicated, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. The policy indicated, 2. Appropriate care and services will be provided for residents who are unable to carry…

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

Based on observations, interviews, and facility document and policy review, it was determined the facility failed to provide treatment to prevent further decrease in range of motion for 1 (Resident #23) of 2 residents reviewed for limited range of motion. The facility census was 57. Findings included: Review of facility policy titled, Restorative Nursing Services, revised in 07/2017, indicated, Residents will receive restorative nursing care as needed to help promote optimal safety and independence. 1. Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitation services (e.g., physical, occupational, or speech therapies). 2. Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care. 5. Restorative goals may include, but are not limited to supporting and assisting the resident in: b. Developing, maintaining or strengthening his/her physiological and psychological resources. Review of a facility policy titled, Resident Mobility and Range…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure ongoing communication and collaboration with the dialysis facility regarding dialysis care and services, and failed to ensure ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility were completed for 1 (Resident #44) of 2 residents reviewed for dialysis. The facility census was 57. Findings included: Review of Resident #44's Face Sheet revealed the resident was readmitted to the facility on [DATE] with a diagnosis that included end stage renal disease. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/17/2023, revealed Resident #44 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident was moderately cognitively impaired. Per the MDS, Resident #44 was receiving dialysis treatment. Review of Resident #44's Care Plan with a problem onset date of 05/23/2023, revealed the resident…

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

Based on record review, interview, and facility policy review, it was determined the facility failed to provide evidence of adequate monitoring for the effects of and/or responses to psychotropic medications for 1 (Resident #49) of 5 residents reviewed for unnecessary medications. The facility census was 57. Finding included: A review of a facility policy titled, Behavioral Assessment, Intervention and Monitoring, revised in 03/2019, indicated, 3. The nursing staff will identify, document, and inform the physician about specific details regarding changes in an individual's mental status, behavior, and cognition, including: a. onset, duration, intensity and frequency of behavioral symptoms. A review of Resident #49's Face Sheet revealed the facility admitted the resident on 08/13/2022 with diagnoses that included other specified depressive episodes. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/14/2023, revealed Resident #49 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident had intact cognition. Per the MDS,…

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, interview, and facility policy review, the facility failed to ensure 1 (Resident #44) of 3 residents who received insulin were free from significant medication errors. Specifically, the facility failed to ensure staff administered Resident #44's insulin as ordered by the physician. The facility census was 57. Findings included: Review of a facility policy titled, Administering Medications, revised April 2019, revealed, Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders, including any required time frame. The policy further indicated If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns. A review of a Face Sheet indicated…

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 resident requests for less than $100.00 ($50.00 for Medicaid residents) were honored within the same day by not assuring residents had access to their trust account on the weekends. This deficient practice affected all the residents who had a resident trust account. The facility also failed to keep resident trust fund (RTF) accounts from being overdrawn for eight residents (Residents #214, #216, #217, #215, #212, #213, #30 and #52). The census was 59. 1. During the resident council group interview on 10/8/19 at 11:00 A.M., six out of six residents agreed the facility does not offer RTF banking hours on the weekends. Observation of the door to the facility business office, showed a sign posted stating, New bank hours: Monday through Friday 10 A.M. -12 P.M. and 2 P.M - 4 P.M. During an interview on 10/9/19 at 11:41 A.M., the administrator said the RTF bank hours were Monday through Friday 10 A.M. -12 P.M. and 2 P.M - 4 P.M. She was not aware residents should have access to funds over the weekend. 2.…

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, when they failed to provide documentation regarding quarterly resident trust fund statements. This affected all residents for whom the facility held funds. The census was 59. During the resident council group interview on 10/8/19 at 11:00 A.M., five out of six residents, whom the facility identified as cognitively intact, agreed the facility did not provide resident trust fund quarterly statements. No one knew their resident trust balance. During an interview on 10/9/19 at 12:38 P.M., the corporate bookkeeper and administrator said there was no documentation of quarterly statements being provided for the last quarter. Typically, they had residents sign the statements, but there was nothing on file to show statements were provided to the residents during the last quarter.

Based on interview and record review, the facility failed to maintain the bond amount for at least one and one-half times the average monthly balance of the residents' personal funds for the last twelve consecutive months from September 2018 to August 2019. The census was 59. Record review on 10/10/19 of the residents' personal funds account for the last twelve consecutive months from September 2018 to August 2019 showed the following: -The facility could not provide a reconciled bank statement for July 2019; - The facility's current approved bond amount equaled $35,000.00; - The average monthly balance for the residents' personal funds equaled $27,533.67; - An average monthly balance of $27,533.67 required a bond of at least $42,000.00. During an interview on 10/10/19 at 12:46 P.M., the corporate bookkeeper said the current bond amount was insufficient. The facility should increase the bond to $50,000.00 for sufficient coverage.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure care plans reflected residents' current needs by not updating them to include a new pressure ulcer (pressure injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or friction), new/additional fall interventions and a resident's risk of pressure ulcers, including treatment and interventions, for three (Residents #5, #37 and #45) of 15 sampled residents. The census was 59. 1. Review of Resident #5's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/10/19, showed the following: -Moderate cognitive impairment; -Unable to ambulate; -Dependent on staff for all mobility and personal care; -Incontinent of bowel and bladder; -Risk of developing pressure ulcers: YES; -No skin breakdown; -Diagnoses included muscular sclerosis (MS-a chronic disease of the central nervous system that affects the brain, spinal cord and optic nerves),…

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 obtained diagnoses for antibiotics and psychotropic medications, clarify the dose of a heparin (blood thinner) flush, obtain code status (full code-all life preserving methods are performed, or no code-no life preserving methods are performed) orders, obtain the liter (L) flow for continuous oxygen administration, provide a diagnosis for the use of a supra-pubic catheter (SP cath-a small tube surgically inserted through the lower abdominal wall into the bladder to drain urine), follow up with the physician regarding a dietician's recommendations, and follow a physician's order for the use of heel protectors. This affected four residents (Residents #260, #259, #210 and #45). The sample size was 15. The census was 59. 1. Review of Resident #260's face sheet, showed the following: -admitted to the facility on [DATE]; -Diagnoses included diabetes, heart disease,stroke, high blood pressure, sepsis (a serious illness that happens…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow their smoking policy by allowing two residents (Residents #12 and #38) to keep cigarettes and a lighter on their persons. The facility also failed to prevent resident access to razors by not removing razors from one resident's room (Resident #210) and allowing storage of razors in an unlocked cabinet drawer in the hall of the 3rd floor. The facility also failed to repair a call light in the 3rd floor shower room, which left exposed wires. The census was 59. Review of the facility's Smoking Policy, dated 9/21/17, showed the following: -All smokers will be supervised by staff to smoke; -All resident cigarettes are stored in container at the main reception desk on the first floor; -Cigarettes are given to the residents inside the smoke room only; -Residents are not allowed to be in possession of lighters and/or matches while inside the facility; -The policy did not state how staff would determine if a resident was safe to engage 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 interview and record review, the facility failed to provide thorough assessments, orders, monitoring and ongoing communication with the dialysis (the clinical purification of blood by dialysis as a substitute for the normal function of the kidney) center for three residents (Residents #49, #22 and #45). The facility identified four residents who received dialysis. Three of them were chosen for the sample of 15 and issues were found with all three of them. The census was 59. 1. Review of Resident #47's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/15/19, showed the following: -No cognitive impairment; -Total dependence on staff for most activities of daily living (ADLs); -Upper extremity impairment on one side; -Incontinent of bowel and bladder; -Received dialysis; -Diagnoses included diabetes and depression. Review of the resident's care plan, updated on 7/20/19, showed the following: -Problem: Required renal dialysis on Monday,…

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 establish a system of records of receipt and disposition of all controlled drugs in a sufficient detail to enable an accurate reconciliation by not ensuring nursing staff signed at the beginning and end of each nursing shift, for two of four narcotic count books checked. The census was 59. 1. Review of the 300 Hall nurse's narcotic count sheet, dated October 2019, showed the following: -From 10/1 through 10/6/19, a total of 10 shifts without the on-coming nursing staff signature and/or initials for counting narcotics; -From 10/1 through 10/6/19, a total of 10 shifts without the off-going nursing staff signature and/or initials for counting narcotics. 2. Review of the 300 Hall Certified Medication Technician (CMT) narcotic count sheet, dated October 2019, showed the following: -From 10/1 through 10/6/19, a total of 5 shifts without on-coming CMT's signature and/or initials for counting narcotics; -From 10/1 through 10/6/19, a total of 4 shifts without off-going CMT's signature and/or initials for counting narcotics. During…

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

Based on observation, interview and record review, the facility failed to follow puree recipes to ensure food was prepared by methods that conserved nutritive value and flavor, for seven of seven residents who received pureed diets. The census was 59. 1. Observation on 10/8/19 at 10:05 A.M., showed [NAME] J stood at a kitchen counter and said he/she would puree seven servings of spaghetti and meatballs, and zucchini for the lunch meal. The blender bowl sat on the counter and contained pasta. [NAME] J said he/she put four tongs full of pasta in the bowl, which was about 8 ounces (oz). He/she added two, 6 oz. (12 oz. total) scoops of spaghetti sauce with an unknown number of meat balls. [NAME] J washed his/her hands, donned gloves and added 2 teaspoons of chicken base to two cups of hot water and stirred the mixture. [NAME] J turned on the blender and added approximately one-half cup of chicken broth. [NAME] J stirred the mixture, added the rest of the liquid, turned the blender back on and continued to blend. The puree tasted strongly like pasta, with a slight taste of the sauce 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, the facility failed to ensure food was dated when placed in the walk-in refrigerator. This deficient practice had the potential to affect all residents who ate at the facility. The census was 59. 1. Observation of the walk in refrigerator, showed the following: -On 10/7/19 at 10:31 A.M. and 5:30 P.M., and 10/8/19 at 10:05 A.M., two large pork tenderloins and four approximate 5 pound (lb) rolls of ground beef sat, undated, on a tray on the bottom shelf; -On 10/9/19 at 2:41 P.M., the pork tenderloins and four rolls of ground beef had a sticker, dated 10/9/19; -On 10/10/19 at 1:21 P.M., four rolls of ground beef, dated 10/9/19, remained on the tray on the bottom shelf and two pork tenderloins were gone. 2. Observation of the reach-in cooler, showed the following: -On 10/7/19 at 3:50 P.M., two boxes of thawed health shakes, dated 10/4/19 with black marker, sat on the shelf; -On 10/8/19 at 10:05 A.M., a box, dated 10/11/19, containing nine thawed strawberry health shakes, sat on the shelf along with an unopened box of chocolate health shakes, 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 interview and record review, the facility failed to collaborate with hospice in the development of a coordinated plan of care for residents receiving hospice care. The facility also failed to maintain documentation of a continuation of services provided when one hospice provider went out of business, until the resident was admitted to another provider (Resident #15). The facility identified two residents who received hospice care. Both residents were included in the sample of 15, and problems were found with each of them (Residents #15 and #37). The census was 59. 1. Review of Resident #15's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/15/19, showed the following: -Severe cognitive impairment; -Unable to ambulate; -Required staff supervision for mobility and personal care; -Diagnoses included high blood pressure, dementia, depression and chronic lung disease; -Life expectancy of less than six months: NO Review of the care plan, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the resident call light system remained functional for four of four shower rooms on the second floor and one shower room on the third floor. This affected all residents who showered in those shower rooms. The census was 59. 1. Observations on 10/7/19 at 11:39 A.M., 10/9/19 at 7:35 A.M., 10/10/19 at 7:35 A.M. and 1:26 P.M. and 10/11/19 at 7:00 A.M., of the third floor unlocked shower room across the hall from room [ROOM NUMBER], showed the call light detached from the wall and not in working order. 2. Observations on 10/11/19 of the second floor shower rooms, showed the following: -At 7:13 A.M., the shower room across from room [ROOM NUMBER] did not sound or light up outside the door when the string was pulled; -At 7:14 A.M., the shower room across from room [ROOM NUMBER] did not light up outside the door when the string was pulled; -At 7:16 A.M., the shower room across from room [ROOM NUMBER] did not sound or light up outside 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 staff failed to accurately code the Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, regarding life expectancy for one resident (Resident #15) and tracheostomy (trach, an opening in the neck to place a tube in the windpipe that allows air to enter the lungs) and the use of oxygen for one resident (Resident #46). The sample size was 15. The census was 59. 1. Review of Resident #15's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Unable to ambulate; -Supervision required for mobility and personal care; -Diagnoses included diabetes, dementia and chronic lung disease; -Life expectancy of less than six months: NO. Review of the medical record, showed he/she admitted to hospice on 2/21/18. Review of the care plan, dated 2/21/18 and last updated 9/10/19, showed the following: -Problem: Resident has chosen to receive hospice services; -Goal: Resident will experience 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 ensure a medication error rate of less than 5%. Out of 26 opportunities, two errors occurred resulting in 7.69% medication error rate (Resident #38). The census was 59. Review of Resident #38's physician's order sheet (POS), dated 10/7/19 through 11/6/19, showed the following: -Diagnoses included high blood pressure and muscle spasms; -An order, dated 8/11/18, to administer Lisinopril (medication used to treat high blood pressure) 20 milligrams (mg), one tablet daily (scheduled administration time 9:00 A.M.) and Baclofen (medication used to treat muscle spasms) 10 mg, one tablet twice daily (BID) (scheduled administration times 9:00 A.M. and 1:00 P.M.). Observation on 10/7/19 at 10:35 A.M., showed Certified Medication Technician (CMT) A administered the resident's medication, except Lisinopril 20 mg tablet and Baclofen 10 mg tablet, due to medications not available for administration. During an interview on 10/7/19 at 11:05 A.M., CMT A said the resident's Lisinopril and Baclofen medications were ordered from…

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.