Estates Of Spanish Lake, The

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident with a mental disorder had a DA-124 Level II evaluation (Pre-admission Screening and Resident Review (PASRR), a comprehensive assessment conducted on individuals identified by a Level I PASARR screening as potentially having a mental impairment or developmental disability) as required, for one resident investigated for PASRR requirement (Resident #106). The census was 140. Review of the facility's Pre-admission Screening and Resident Review Process, reviewed on 1/24/24, showed: -Purpose: Our facility will follow the Missouri Department of Health and Senior Services in obtaining the PASARR to determine the psychological needs they require based on their past history, allowing the facility to provide individualized care; -Process: -Prior to admission the DA 124 is completed while in the hospital; -The code is verified on the Central Office Medical Review Unit (COMRU) website to ensure it has been filled out completely; -COMRU website…

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 resident care plans were updated and accurate to reflect resident needs. This failure affected three residents, whose care plans did not address recent self-harming behaviors, dialysis and discharge planning (Residents #43, #121 and #120). The sample size was 29. The census was 140. Review of the facility's Care Plan and Care Plan Conference Policy, dated 8/24/24, showed: -Policy: A care plan shall be used in developing the resident's daily care routine and will be available to the team for review to ensure the best person-centered care is provided to our residents. Every quarter, an attempt will be made to schedule a care plan conference with the resident, family and/or responsible party to allow the staff to provide the best person-centered care; -Procedure; -An interim care plan will be completed by the Nursing Deportment within 24 hours of admission and provided to the responsible party within 48 hours of admission; -The Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure services provided met acceptable professional standards of care when staff failed to transcribe one resident's new order into the computer, resulting in the resident's urine analysis (UA, urine to check for signs of disease or infection) and culture and sensitivity (C/S, a lab test to attempt to grow bacteria, viruses, or fungi. and then test which medications will effectively work to stop the infection) not being obtained (Resident #68). Staff also failed to obtain a physician order for one resident's oxygen (Resident#31). The sample was 29. The census was 140. Review of the facility's Physician Orders policy, dated 8/24/24, showed: -Purpose: The purpose of this policy is to ensure our residents receive the care prescribed by their physician; -The Registered Nurse (RN)/Licensed Practical Nurses (LPN) and Certified Medication Technicians (CMT) are to follow the orders as written. 1. Review of Resident #68's significant change…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure staff followed their policy for dialysis (a procedure that cleanses the blood of its impurities) when staff failed to assess/document the dialysis catheter (a catheter used for exchanging blood to and from a hemodialysis machine and a patient) or arteriovenous fistula, (AV, a surgical connection between an artery and a vein, usually in the arm, that's used for dialysis) site every shift and failed to fully complete the dialysis communication forms for two out of two residents who were receiving dialysis services (Residents #121 and #104). In addition, the facility failed to have a physician order for dialysis for one resident (Resident #104) and failed to have a contract with the dialysis companies. The sample was 29. The census was 140. Review of the facility's Management of a Resident Receiving Dialysis policy, dated 2/22/25, showed: -General guidelines: monitor the resident for the following problems associated with renal failure and/or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure staff accurately administered/documented medications, weekly skin assessments, pain and behavior monitoring, as well as blood pressure, per physician orders for two residents (Resident #31 and #62). The sample was 29. The census was 140. Review of the facility's Administering Medication policy, dated 1/24/24, showed: -Policy: Medications will be administered in a safe and timely manner, and as prescribed; -Only persons licensed or permitted by the state of Missouri to prepare, administer and document the administration of medications and/or have related functions can administer medications; -The Director of Nursing (DON) or designee will supervise and direct all nursing personnel who administer medications and/or have related functions; -Medications must be administered in accordance with the orders, including any required time frame; -If a medication is withheld, refused or given at a time other than the scheduled time the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy and ensure staff reported an allegation of sexual abuse, resulting in a delayed abuse investigation regarding two residents (Resident #1 and Resident #2). The sample was six. The census was 132. Review of the facility's Abuse, Neglect, and Exploitation policy, undated, showed the following: -Policy: Each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. The resident has the right to be free from mistreatment, neglect and misappropriation of property. -Resident must not be subject to abuse by anyone, including, but not limited to: Facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members, legal guardians, friends or other individuals; -When suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur, it must be communicated to the facility's Administrator,…

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 call lights were accessible to residents while in their rooms for five out of five sampled residents (Resident #5, #11, #12, #13 and #15). This had a potential to affect all residents. The census was 127. 1. Review of Resident #5's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/14/24, showed: -Cognitively intact; -Had impaired vision; -Impairment on one side of upper and lower body; -Always incontinent of bladder; -Frequently incontinent of bowel; -Dependent on staff for toileting and transfers from the bed/chair; -Required moderate assistance for rolling left and right in the bed; -Required maximal assistance to transfer from a lying to sitting position and from a sitting to lying position; -Used a wheelchair for mobility; -Diagnoses included heart failure, stroke, diabetes, respiratory failure, muscle weakness, cognitive communication deficit and seizure disorder.…

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 pain medications were given as ordered for one of three sampled residents (Resident #14). The census was 127. Review of the facility's Administering Medication Policy, reviewed on 1/24/24, showed: -Policy: Medications will be administered in a safe and timely manner, and as prescribed; -Medications must be administered in accordance with the orders, including any required time frame; -If a medication is unavailable, the Certified Medication Technician (CMT)/Nurse will look in the First Dose Cabinet and/or central supply for over-the-counter medications, and administer the medication. If the medication is still unavailable, the CMT/Nurse will reorder the medication by either faxing or calling the request into the pharmacy; -If a medication is missing, and the pharmacy has not sent the requested medication the following day, the Director of Nursing or designee is to be notified to assist in removing barriers and obtaining the medication in a timely manner, whether the issue lies within the pharmacy or a new…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure nurses completed weekly skin assessments, weekly wound assessments and to ensure treatments were applied as ordered to pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), for one resident (Resident #5) out of three sampled residents. The facility also failed to ensure facility wound reports were accurate. This had the potential to affect all residents at risk for skin breakdown. The census was 127. Review of the National Pressure Ulcer Advisory Panel (NPUAP), prevention and treatment of pressure ulcers: Quick Reference Guide, Washington DC: National Pressure Ulcer Advisory Panel 2014 showed the following: -Assess the pressure ulcer initially and re-assess it at least weekly; -With each dressing change, observe the pressure ulcer for signs that indicate a change in treatments as required (e.g., wound…

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 colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall) services received such care consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences for one resident (Resident #7) out of three sampled residents. The census was 127. Review of the facility's Administering Medication Policy, reviewed on 1/24/24, showed: -Policy: Medications will be administered in a safe and timely manner, and as prescribed; -Only persons licensed or permitted by the state of Missouri to prepare, administer and document the administration of medications and/or have related functions can administer medications; -Medications must be administered in accordance with the orders, including any required time frame; -Topical medications used in treatments will be documented on the Treatment Administration Record…

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 policy review, the facility failed to post contact information for Adult Protective Services (APS) and the Medicaid Fraud Control Unit. This had the potential to negatively affect the residents' right to contact the agencies for 118 of 118 residents who resided at the facility. The census was 118. Findings include: Review of the facility's policy and procedure titled, Agency Postings, dated December 2022, revealed, . This policy covers the posting of Agencies and ensures their contact information is made available to residents, staff and family members to report alleged concerns or questions to ensure the highest quality of care. 2. Department of Health and Senior Services Abuse and Neglect contact Information . On 01/17/24 at 3:14 PM, observation and review of the facility's required posting of contact information for pertinent State agencies and advocacy groups revealed no contact information for Adult Protective Services or the local contact agency for Medicaid was posted. In an interview on 01/17/24 at 3:14 PM, the Director of Operations…

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, interviews, and policy review, the facility failed to provide eight hours of Registered Nurse (RN) coverage on 31 out of 109 days reviewed for staffing. This had the potential to cause unmet health needs for 118 of 118 residents who resided at the facility. Findings include: Review of facility provided policy titled, Nursing Staffing Policy, dated 12/22/21, revealed, . This facility will maintain nursing staffing ratios to ensure appropriate care is provided . We will have a registered nurse 8 hours a day 7 days a week . Review of the facility's Daily Staffing Sheets, provided by the facility and dated 10/01/23 through 01/17/24, revealed no evidence of RN coverage for an eight-hour shift for the following dates: 10/01/23, 10/08/23, 10/14/23, 10/15/23, 10/21/23, 10/22/23, 10/28/23, 10/29/23, 11/04/23, 11/05/23, 11/11/23, 11/12/23, 11/18/23, 11/19/23, 11/25/23, 11/26/23, 12/03/23, 12/09/23, 12/10/23, 12/16/23, 12/23/23, 12/24/23, 12/25/23, 12/30/23, 12/31/23, 01/01/24, 01/06/24, 01/07/24, 01/13/24, 01/14/23, and 01/17/24. During an interview on 01/19/24 at…

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

Based on record review, interview, and policy review, the facility failed to ensure the required staff members (Director of Nursing (DON), Infection Preventionist (IP), and Medical Director) of the Quality Assurance (QA) Committee attended at least the quarterly QA meetings for one of four quarters. Additionally, the IP failed to attend at least quarterly QA meetings for four of four quarters. The total census was 118. Findings include: Review of facility policy titled, The Estates Quality Assurance Performance Improvement (QAPI), revised March 2022, revealed Our QAPI represent our facility's commitment to continuous quality improvement. The program ensures a systematic performance evaluation, problem analysis and implementation of improvement strategies to achieve our performance goals. Policy Explanation and Compliance Guidelines . 2. The facility shall establish an interdisciplinary QAPI committee. The committee shall consist of, at a minimum, Administrator, Director of Nursing Services (DNS), physician, and three other facility staff members. Additional staff members may be…

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 policy review, the facility failed to provide or help arrange resident council meetings on a regular basis for five of five sampled residents (Resident (R) 355, R16, R85, R35, and R67) who attended the resident council meeting. The census was 118. Findings include: Review of the facility's policy and procedures titled, ''Resident Council Policy,'' dated 12/21/20, revealed, ''. The Resident Council is a meeting that is held one time per month in a designated location in facility .'' During a meeting with the resident council on 01/16/24 at 11:00 AM, R355, R16, R85, R35, and R67 all stated there were no resident council meetings on a regular basis. Review of R355's quarterly ''Minimum Data Set (MDS)'' with an Assessment Reference Date (ARD), located under the ''MDS'' tab of the electronic medical record (EMR), revealed R355 had a ''Brief Interview for Mental Status (BIMS)'' score of 14 out of 15, which indicated R355 was cognitively intact. Review of R16's quarterly ''MDS'' with an ARD of 12/08/23 and located under the ''MDS'' tab of the…

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

Based on interview and record review, the facility failed to have a system in place to ensure residents were not allowed to spend another resident's money without written authorization, causing individual resident trust fund accounts to go into a negative balance. The facility managed funds for 93 residents. A sample of 13 were chosen and the practice affected all 13 residents (Residents #102, #91, #1, #87, #3, #13, #97 #101, #103, #8, #6, #78 and #2). The census was 118. Review of the facility's Management/Protection of Resident Funds Policy, dated 4/3/19, showed the following: -A record of all transactions regarding the resident's funds shall be maintained by the facility in accordance with the generally accepted accounting principles; -The facility has a surety bond to assure the security of the president's personal fund deposited with the facility; -All residents' personal funds shall be deposited in a passbook type interest bearing account and shall be subject to the terms and the conditions imposed by the financial institution where such account is located; -There was no…

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

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment on two of seven halls in ten resident rooms (Resident (R) 84, R58, R53, R44, R25, R76, R61, R78, R87 and R46). The census was 118. Findings include: 1. During observational tour of the facility on the first floor B-hall on 01/15/24 between 09:50 AM-10:50 AM the following environmental concerns were identified: In R84's room the overbed table had one side with chipped off wood. The one side of the overbed table appeared as it was chewed off. R58's closet door had no knobs. R53's bedroom door had peeling paint on the bottom left side of the door, peeling paint on the wall in the upper left corner of the wall near door frame, and bathroom wall next to the toilet, has peeling paint. R44's closet door was off the track, leaning on the wall, which was on the right side of the room after entering. During an interview on 01/18/24 at 3:00 PM, R44 stated the door had been off the track and leaning for a long time, he/she could not remember how long. 2. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to address a verbal grievance related to missing clothing for one of 32 sampled residents (Resident (R) 85) and failed to ensure five of five residents interviewed in the resident council (Resident (R) 355, R16, R85, R35, and R67) had knowledge of the facility's grievance process. The census was 118. Findings include: Review of the facility's undated Abuse and Neglect Policy revealed, ''. Prevention of Abuse, Neglect, and Exploitation The facility will consider utilization of the following tips for prevention of abuse, neglect, and exploitation of residents: Provide feedback to residents, staff and family members who voice grievances .'' Review of the facility's policy and procedure titled, ''Resident Rights'' dated 12/01/19, revealed, ''. Residents have the right to voice grievances .'' 1. Review of R85's ''Face Sheet,'' provided by the facility, revealed an admission date of 09/08/21. Review of R85's quarterly ''Minimum Data Set…

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 four of 10 sampled employees hired since the last survey. The facility hired at least 200 new employees since the last survey. The census was 118. Review of the facility's Abuse, Neglect and Exploitation Policy, undated, showed the following: -Policy: Each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. The resident has the right to be free from mistreatment, neglect and misappropriation of property. Residents must not be subject to abuse by anyone, including, but not limited to; facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members, legal guardians, friends or other individuals; -Facility Abuse Prevention Plan: -Employee Screening: Background, reference and credentials' checks should be conducted on employees prior to or at the time of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to report allegations of resident-to-resident physical abuse, sexual abuse, and violent behaviors to the facility's Abuse Coordinator and the state survey agency for four of nine sampled residents (Resident (R) 59, R73, R84, and R4) reviewed for abuse. These failures presented a potential for continued abuse. The census was 118. Findings include: Review of the facility's undated policy titled ''Abuse, Neglect and Exploitation,'' revealed, ''. anyone in the facility can report suspected abuse to the abuse hotline. The facility Administrator/designee must ensure that all alleged violations, involving abuse are, or have a result in a significant injury, are reported immediately, but no later than 2 hours after the allegation is made .'' 1. Review of R59's ''admission Record,'' located in the ''Profile'' tab of the electronic medical record (EMR), revealed he/she was initially admitted to the facility on [DATE] and was readmitted on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to investigate allegations of resident-to-resident physical and sexual abuse and violent behaviors for seven of nine sampled residents (Resident (R) 59, R73, R4, R77, R84, R30, and R83) reviewed for abuse. The census was 118. Findings include: Review of the facility's undated policy titled, ''Abuse, Neglect and Exploitation'' revealed, ''. Investigation of alleged abuse, Neglect and Exploitation. When suspicion of abuse, neglect, or exploitation or reports of abuse occur, it must be communicated to the facility's Administrator, Department Head or Supervisor and the Administrator/designee must initiate an investigation. Interview all residents involved and all witnesses separately. Document the entire investigation chronologically .'' 1. Review of R59's ''admission Record,'' located in the ''Profile'' tab of the electronic medical record (EMR), revealed he/she was initially admitted to the facility on [DATE] and was readmitted on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. R203's ''Face Sheet,'' dated 01/20/24, indicated R203 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia, history of TBI, major depression, history of alcohol abuse, psychoactive, abuse, PTSD, mild intellectual disabilities, epilepsy, and violent behavior. R203's quarterly MDS'' assessment with an ARD of 11/18/23 indicated a ''BIMS'' of 8 out of 15 (moderately cognitively impaired). The assessment indicated the resident experienced delusions and exhibited verbal aggression toward others frequently during the assessment reference period. R203's ''Behavior Care Plan,'' found in the EMR under the ''Care Planning'' tab and dated initiated on 10/02/23 and then most recently updated on 11/23/23 read, ''BEHAVIORS/ PSYCHOSOCIAL WELLBEING: [R203] shows aggressive behaviors by punching items, walls, and mailbox. He has dx [diagnoses] of Intellectual Disabilities, Malingering, PTSD, Factitious D/o [disorder], Suicidal Ideations. He has drunk hand sanitizer because he is 'just tired of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide treatment and services for mental and psychosocial concerns for three of 24 residents (Resident (R) 61, R78, and R209). Specifically, the facility failed to provide appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for the residents with diagnosed mental disorders and post-traumatic stress disorder. The census was 118. Findings include: A policy and procedure for providing the residents with psychiatric services was requested on 01/19/24 at 10:59 AM. No policy or procedure was provided as of 01/20/24 at the time of exit. 1. Review of R61's ''Census'' located under the ''Clinical'' tab in the electronic medical record (EMR) revealed R61 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, Tourette's disorder, post-traumatic stress disorder (PTSD), generalized anxiety disorder, irritability and anger, bipolar…

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 two of two sampled residents (Resident (R) 21 and R209) reviewed for self-administration of medication were safe to self-administer their own medications. R21 had an unlabeled respiratory inhaler medication at her bedside and R209 had expired topical and oral medications at his bedside. Neither resident had orders to self-administer the observed medications. The census was 118. Findings include: The facility's ''Self-Administration of Medications Protocol'' dated [DATE] read, in pertinent part: ''Purpose: To address a resident's expressed interest in increasing their independence with medication administration, by being able to keep medications at bedside or being able to self-administer medications, as well as, to determine if they are safe/capable to do so;''; ''2. The Charge Nurse will complete a Self-Administration of Medication Assessment on the resident;'' 4. The Director of Nursing and/or Assistant Director of…

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

Based on interview and record review, the facility failed to ensure residents and/or responsible parties were notified in a timely manner when a resident's account was within the $200.00 Social Security (SSI) limit ($5,726.00) or when the resident's account was over the SSI limit. This affected three residents reviewed who received Medicaid benefits (Residents #104, #14 and #16). The census was 118. Review of the facility's Management/Protection of Resident Funds Policy, dated 4/3/19, showed the following: -If the resident receives Medicaid benefits, the Facility shall notify the resident when the amount in his/her account has reached $200.00 less than the Social Security Income (SSI) resource limit for one person, and that if the amount in the account in addition to the value of the resident's other non-exempt resources reaches the SSI resource limit for one person, the resident may lose eligibility for Medicaid or SSI. 1. Review of Resident #104's Resident Trust Statement, dated 12/31/23, showed the following: -10/31/23, ending monthly balance of $20,398.87; -11/30/23, ending…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility policy review, and interview, the facility failed to ensure the Ombudsman was notified of hospital transfers for one resident of four residents (Resident (R) 88) reviewed for hospitalizations. Findings include: Review of facility policy, titled Estates Notice of Transfer or Discharge of Nursing Home Resident, dated 04/10/21, revealed, Residents/Resident's Legal Representative shall receive written notification if a resident is temporarily discharged /transferred to the hospital due to an urgent medical need. Procedure . 7. The admission Coordinator will retain a copy of the form and notify the Ombudsman of all discharges, including temporary discharges, on a monthly basis. Review of Face Sheet, provided by the facility, revealed R88 was readmitted on [DATE] with a diagnosis of cirrhosis of the liver, malignant neoplasm of colon, dementia, and chronic obstructive pulmonary disease (COPD). Review of Progress Note, dated 07/15/23 and provided by the facility, revealed [R88] had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure one resident out of two residents (Resident (R) 58) reviewed for hospice had a significant change in status Minimum Data Set (MDS) assessment completed within 14 days of being admitted to hospice. The census was 118. Findings include: Review of Center for Medicare and Medicaid Services (CMS) Long-term Care Facility Assessment Instrument 3.0 User's Manual, version 1.18.11, dated October 2023, revealed, Chapter 2: Assessments for the Resident Assessment Instrument, 2.6: Required OBRA Assessments for the MDS .RAI OBRA-required assessment summary for significant change in status . Assessment Reference Date (ARD) no later than 14th calendar day after determination that significant change in resident's status occurred (determination date + 14 calendar days). Review of facility provided Face Sheet revealed R58 was re-admitted to the facility on [DATE] with a diagnosis including malignant…

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, record review, and policy review, the facility failed to incorporate the recommendations from the PASRR (Pre-admission and resident review) Level II determination and the PASRR evaluation report for two of 24 resident's (R) 46 and R61) plan of care. Specifically, the coordination did not occur as the PASRR Level II evaluation reports were not part of the residents' electronic medical record. The census was 118. Findings include: Review of the facility's ''Pre-admission Screening and Resident Review'' policy, dated 06/18/23, revealed the facility will follow the State Survey Agency and Senior [NAME] in obtaining the Pre-admission Screening and Resident Review (PASRR) to determine the psychological needs they require based on their past history, allowing the facility to provide individualized care. The Central Office Medical Review Unit (COMRU) website will alert the facility if a Level Il was triggered and when the assessment will be completed. Once the Level 2 has been completed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to ensure that one resident of one resident reviewed for dialysis (Resident (R) 50) had communication between the facility and dialysis. In addition, the facility failed to ensure that R50's dialysis port was being assessed for signs and symptoms of infection as per facility policy. The census was 118. Findings include: Review of the facility policy titled, Management of a Resident Receiving Dialysis, reviewed 03/22/23, revealed, General Guidelines: 1. Monitor the resident for the following problems associated with renal failure and/or dialysis: a. Fluid and electrolyte imbalance b. Cardiovascular/hemodynamic instability c. Pain d. Infection e. Altered nutrition f. Immobility 2. Assess dialysis catheter or Arteriovenous (AV) fistula every shift and document. 3. Cover dialysis catheter before resident bathes or showers. Ensure catheter dressing is dry and intact. 4. A care plan should be initiated to determine the needs of the resident 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 record review, interview, and policy review, the facility failed to ensure that physician follow-up to the pharmacist recommendations was implemented for two of five residents (Resident (R) 9 and 21) reviewed for unnecessary medications. The census was 118. Findings include: 1. Review of facility provided Face Sheet revealed R9 was re-admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease and major depressive disorder (MDD). Review of facility provided Medication Regimen Review Prescriber Recommendation (the document utilized by the facility to indicate the monthly pharmacist's recommendations and subsequent review by the resident's physician), dated 06/29/23, revealed This resident is receiving Aripiprazole [Abilify, anti-psychotic medication] 5 mg [milligrams] PO [by mouth] once daily for dementia with behavioral disturbance (started 01/07/23), and mirtazapine [Remeron, anti-depressive medication] 45 mg PO at bedtime [HS] for depression (started 01/06/23). Please consider one of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure that the copy of the signed agreement for binding arbitration for three residents (Resident (R) 30, 78, and 354) did not include if the resident revokes the agreement the facility may terminate agreement and have resident vacate the facility within 60 days. The census was 118. Findings include: 1. Review of facility provided Face Sheet revealed R30 was re-admitted on [DATE]. Review of R30's facility provided Exhibit A Arbitration Agreement, signed by R30's guardian and dated 04/17/23, revealed, .Section 8. Freedom of Choice/Right to Revoke a. The resident is under no obligation to reside at the facility. There are other long term care facilities which are available to resident in the event this arbitration agreement is unacceptable to resident. b. This arbitration agreement may be revoked by resident upon written notice delivered to the administrator of facility within 30 days of the original execution by resident. If resident revokes this…

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 3XlJ12. Based on interview and record review, the facility failed to keep residents free from physical abuse when Resident #1 and a staff member had a verbal altercation, which escalated into the staff member smacking a cigarette out of the resident's mouth during a smoke break. The staff member also cursed at the resident and used threatening language and posture. The staff member intentionally broke the resident's cigar in half, threw it on the ground and told the resident to pick it up. The sample was three. The census was 114. The Administrator was notified on 10/17/23, of the past non-compliance. Upon learning of the incident, facility management removed the alleged staff member from the building. The facility in-serviced staff on the abuse/neglect policy, with a special emphasis on verbal abuse on 9/22/23. The deficiency was corrected on 9/22/23. Review of the facility's Abuse, Neglect and Exploitation policy, updated 11/30/17, showed the following: -Each resident has the right to be free from verbal, sexual, physical and mental abuse,…

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 3XlJ12. Based on interview and record review, the facility failed to follow their policy, and state and federal regulations, by not notifying the Department of Health and Senior Services (DHSS) immediately or within the required two hour time-frame, after being made aware of an allegation of employee to resident abuse for one of three residents reviewed for abuse and neglect investigations (Resident #1). The census was 114. Review of the facility's Abuse, Neglect and Exploitation policy, updated 11/30/17, showed the following: -Each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. The resident has the right to be free from mistreatment, neglect and misappropriation of property. Resident must not be subject to abuse by anyone, including, but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members, legal guardians, friends or other individuals; -Policy Explanation and Compliance Guidelines:…

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 3XlJ12. Based on interview and record review, the facility failed to follow their policy to thoroughly investigate an allegation of employee to resident abuse for one of three residents reviewed for abuse and neglect investigations (Resident #1). The census was 114. Review of the facility's Abuse, Neglect and Exploitation policy, updated 11/30/17, showed the following: -Each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. The resident has the right to be free from mistreatment, neglect and misappropriation of property. Resident must not be subject to abuse by anyone, including, but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members, legal guardians, friends or other individuals; -Policy Explanation and Compliance Guidelines: -The Abuse Coordinator in the facility is the Administrator or facility appointed designee. Report allegations or suspected abuse, neglect, or exploitation immediately…

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

Based on interview and record review, the facility failed to follow their policy, and state and federal regulations, by not notifying the Department of Health and Senior Services (DHSS) immediately or within the required two hour time-frame, after being made aware of an allegation of employee to resident abuse for one of three residents reviewed for abuse and neglect investigations (Resident #1). The census was 114. Review of the facility's Abuse, Neglect and Exploitation policy, updated 11/30/17, showed the following: -Each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. The resident has the right to be free from mistreatment, neglect and misappropriation of property. Resident must not be subject to abuse by anyone, including, but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members, legal guardians, friends or other individuals; -Policy Explanation and Compliance Guidelines: -The Abuse Coordinator in the facility is the…

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

Based on interview and record review, the facility failed to follow their policy to thoroughly investigate an allegation of employee to resident abuse for one of three residents reviewed for abuse and neglect investigations (Resident #1). The census was 114. Review of the facility's Abuse, Neglect and Exploitation policy, updated 11/30/17, showed the following: -Each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. The resident has the right to be free from mistreatment, neglect and misappropriation of property. Resident must not be subject to abuse by anyone, including, but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members, legal guardians, friends or other individuals; -Policy Explanation and Compliance Guidelines: -The Abuse Coordinator in the facility is the Administrator or facility appointed designee. Report allegations or suspected abuse, neglect, or exploitation immediately to: -Administrator; -Other Officials…

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 complete and accurate accounting of the resident trust account by not showing what the adjustments were for when reconciling the monthly trust account for 12 of 12 months reviewed. The census was 67. Review of the resident trust account reconciled bank statements, showed the following: -In 4/2020, an adjustment of $11,141.78 was made. No explanation of what the adjustment was for; -In 5/2020, an adjustment of $11,752.73 was made. No explanation of what the adjustment was for; -In 6/2020, an adjustment of negative $623.98 was made. No explanation of what the negative adjustment was for; -In 7/2020, an adjustment of negative $2448.02 was made. No explanation of what the negative adjustment was for; -In 8/2020, an adjustment of negative $512.04 was made. No explanation of what the negative adjustment was for; -In 9/2020, an adjustment of negative $6,976.78 was made. No explanation of what the negative adjustment was for; -In 10/2020, an adjustment of $3,952.60 was made. No explanation of what the adjustment was for;…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure they maintained a surety bond for the resident trust fund account in the amount of one and one half times the average monthly balance for the past 12 months. The census was 67. Record review of the resident trust account for the past 12 months from [DATE] to [DATE], showed an average monthly balance of $59,000. This would yield a required bond in the amount of $88,500 (one and one half times the average monthly balance). Review of the bond report for approved facility bonds by Department of Health and Senior Services (DHSS), showed an approved bond of $80,000 dated [DATE]. Review of the Surety Rider provided by the facility, showed an increase on [DATE] for $120,000. No where on the Rider did it show it had been submitted to DHSS for approval. During an interview on [DATE] at 1:35 P.M., the corporate business manager said she thought the previous Rider had expired. The owner is responsible for the oversight of the Rider.

Based on observation, interview, and record review, the facility failed to develop and/or implement person-centered comprehensive care plans to accurately reflect individual care needs for four residents (Residents #204, #252, #157, and #152). The sample size was 17, with an expanded sample of 13. The census was 67. 1. Review of Resident #204's medical record, showed: -Diagnoses included muscle weakness, neuropathy (nerve damage affecting the nervous system), depression, chronic kidney disease (impaired kidney function), urinary retention and hematuria (blood in urine); -A physician's order, dated 11/18/20, for Fentanyl (narcotic pain medication) 25 microgram (mcg)/hour (hr), apply to skin topically one time a day every 3 days for pain; -A physician's order, dated 11/18/20, for oxycodone/acetaminophen (narcotic pain medication) tab 10-325 milligram (mg), one tablet by mouth every 8 hours as needed for pain; -A physician's order, dated 11/18/20, for Aspercreme with lidocaine (topical anesthetic) 4%, apply to both hands two times a day for pain/stiffness; -A physician's order, 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 staff obtained and document neurological assessments (neurochecks) for the 72 hours following unwitnessed falls, and to complete fall incident reports for three residents (Residents #205, #52 and #204). The facility also failed to ensure staff documented the administration of resident medications and accu-checks (blood sugar readings) according to physician's orders (Residents #203, #251, #58, #157 and #53). The sample was 17. The census was 67. 1. Review of Resident #205's face sheet, showed diagnoses included seizure disorder, convulsions, intellectual disability, depression, abnormalities of gait and mobility, and generalized muscle weakness. Review of the resident's medical record, showed: -Fall risk evaluation, dated 6/26/20, identified the resident at risk of falls; -A progress note, dated 11/28/20 at 12:57 P.M., in which staff documented the resident heard screaming, My left shoulder hurt. Upon entering the resident's room,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents received restorative therapy (RT) as ordered. The facility identified eight residents that should receive RT services. Of those eight, seven were sampled and one of those seven had a decline in their physical abilities. In addition, the facility was unable to provide documentation showing any of the seven resident's received RT services as ordered. (Residents #201, #152, #157, #52, #54, #55, and #253). The census was 67. 1. Review of Resident #201's medical record, showed diagnoses included dementia, seizures, unsteadiness on feet, fracture around prosthetic right hip, fracture at right femur (bone located in the thigh of the upper leg) and history of falling, unspecified abnormalities of gait and mobility. Review of the resident's care plan, initiated on 10/20/20, last revised on 4/6/21, showed: -Problem: At risk for falls related to decreased safety awareness, poor judgment, history of muscle weakness, history of dementia 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 other interventions were tried prior to the use of side rails, properly assess residents for the use of side rails, and update resident care plans regarding the use of side rails. The facility identified 10 residents who utilized side rails in the facility. Five of the residents who utilized side rails were sampled and problems were identified with all five (Resident #157, #152, #204, #103 and #105). The sample size was 17. The census was 67. 1. Review of Resident #157's medical record, showed diagnoses included osteoarthritis of the knee, obesity, unspecified abnormalities of gait and mobility and generalized muscle weakness. Review of the resident's care plan, last updated on 9/22/20 and in use during the survey, reviewed on 4/5/21, showed: -Problem: Has an ADL (activities of daily living) self-care performance deficit related to obesity; -Goal: Will maintain current level of function through the next review; -Interventions: Call light within reach, therapy evaluation and treat as needed, and 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 interview and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation. The controlled substance shift change count check sheets were missing documentation for three of the six facility medication carts. The census was 67. 1. Review on 4/1/21 at 8:27 A.M., of the facility's first floor Controlled Substance Shift Change Check Sheet, dated March 2021, completed by the nurse, showed the following: -60 of 93 shifts, staff failed to count the number of narcotic cards; -67 of 93 shifts, staff failed to document initials to indicate the count was correct. During an interview on 4/1/21 at 8:31 A.M., Nurse G said each nurse is to count each narcotic cards and document the amount of cards on the Controlled Substance Shift Change Sheet. The oncoming and offgoing nurse should initial the sheet to indicate the count is correct. 2. Review on 4/1/21 at 8:50 A.M., of the facility's first floor Controlled Substance Shift Change Check Sheet, completed by the Certified…

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 its medication error rates were not 5% or higher. Out of 33 opportunities for error, four errors occurred, resulting in a 12.12% medication error rate (Residents #154, #253 and #255). The census was 67. 1. Review of Resident #154's physician's order sheets (POS), dated 4/5/21, showed the following: -An order, dated 8/19/20, for Incruse Ellipta 62.5 mcg (a prescription medication used to treat chronic obstructive pulmonary disease (COPD, a group of lung disease that block airflow and make it difficult to breathe and emphysema (lung condition that causes shortness of breath)), inhaler; Give one puff orally one time a day for COPD; -An order, dated 8/19/20, for Breo Ellipta 100/25 (a prescription medication used to treat chronic obstructive pulmonary disease and asthma (a condition causing difficulty in breathing)) inhaler; Inhale one puff orally one time a day for COPD; -Diagnoses included COPD. Observation on 4/5/21 at 7:50 A.M., showed Certified Medication Technician (CMT) B administered medications to…

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

Based on observation, interview, and record review, the facility failed to ensure staff completed routine inspections of bed frames, mattresses, and bed rails to identify areas of possible entrapment with side rail usage to reduce the risks of accidents. The facility identified 10 residents with side rails in use. Five of the residents were sampled and problems were identified with all five (Residents #157, #152, #204, #103 and #105). The sample size was 17. The census was 67. 1. Review of Resident #157's medical record, showed diagnoses included osteoarthritis of the knee, obesity, unspecified abnormalities of gait and mobility and generalized muscle weakness. Review of the resident's care plan, last updated on 9/22/20 and in use during the survey, showed: -Problem: Has an ADL (activities of daily living) self-care performance deficit related to obesity; -Goal: Will maintain current level of function through the next review; -Interventions: Call light within reach, therapy evaluation and treat as needed, and resident will allow staff to assist with bathing, dressing, transfers 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 treat each resident with respect and dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for one of 17 sampled residents (Resident #253). The facility census was 67. Review of the facility's resident rights policy, dated 12/1/19, showed the following: -Policy: To provide quality healthcare through communications, respect and sensitivity between the residents and those who provide them care. The facility strives to promote the exercise of rights for each resident, even if he or she is determined incompetent, should be able to assert these rights based on his or her degree of capability; -All of the facility residents have the following rights: Dignity, privacy and respect; The right to be treated with consideration and respect for personal dignity in personal care and communication. Review of Resident #253's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by…

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 the necessary services to maintain good grooming and personal hygiene for four residents who required staff assistance for performance of activities of daily living (Residents #204, #163, #152, and #103). The sample size was 17. The census was 67. 1. Review of Resident #204's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/27/21, showed: -Rejection of care not exhibited; -Limited assistance of one person physical assist required for dressing and personal hygiene; -Diagnoses included depression and generalized muscle weakness. Review of the resident's care plan, undated and in use at the time of survey, showed no documentation of the resident's preferences for bathing or grooming Observation and interview on 4/2/21 at 7:45 A.M., showed the resident sat in a wheelchair in his/her room with a scruffy beard on his/her cheeks and chin. The resident said he/she cannot stand in the shower, so facility staff usually give him/her bed baths;…

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

Based on interview and record review, the facility failed to provide an ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, for three of three residents sampled for activities (Residents #252, #207, and #208). The census was 67. 1. Review of Resident #252's medical record, showed diagnoses included depression. Review of the resident's care plan, undated and in use at the time of survey, showed: -Problem: The resident has depression related to: staff left blank; -Goal: The resident will exhibit indicators of depression, anxiety, or sad mood less than daily by review date; -Approaches: staff left blank; -No documentation of the resident's activity preferences. Further review of the resident's medical record, showed no documentation of activity assessments or activity participation from August 2020 through April 2021. 2. Review of Resident #207's medical record, showed diagnoses included depression. Review of the resident's care plan, undated and 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.

Based on observation, interview and record review, the facility failed to notify the physician in a timely manner of a change in condition for one of two closed record sampled residents (Resident #102). The census was 67. Review of Resident #102's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/27/19, showed: -Diagnoses of Multiple Sclerosis, high blood pressure, diabetes and dementia; -Short/long term memory problems; -Required extensive staff assistance for eating; -Required total staff assistance for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing; -Incontinent of bowel and bladder. Review of the resident's progress notes, showed: -3/22/2020 at 7:29 A.M.: Abdomen girth is very distended with very faint bowel sounds noted. Denies complaints of pain when touched. Respirations even and unlabored. Slept this shift without difficulty. Findings reported to oncoming Nurses; -3/22/2020 at 7:52 A.M.: Small Bowel movement noted. Small amount of coffee ground emesis (vomit) noted at the end of…

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

Based on observation, interview and record review, the facility failed to identify two unstageable pressure ulcers on a resident's sole of the right foot and the heel of the right foot. In addition, nurse's failed to complete the resident's weekly skin assessments routinely and a certified nursing assistant (CNA) failed to remove the resident's socks during bathing to check for skin breakdown. The resident was not one of three residents the facility identified with a known pressure ulcer (Resident #55). The census was 67. Review of the facility Pressure Ulcer Risk Assessment policy, revised 4/20, showed: Policy: -It is the policy of this facility to perform a pressure ulcer risk assessment as part of our systematic approach for pressure ulcer prevention. A risk assessment does not always identify who will develop a pressure ulcer, but will determine which residents are more likely to develop a pressure ulcer; Policy Explanation and Compliance Guidelines: -Pressure ulcer risk assessments will be conducted by a licensed or registered nurse on admission/re-admission, weekly times four…

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 interventions, including adequate supervision, consistent with a resident's needs, goals, care plan and current professional standards of practice in order to eliminate the risk and/or reduce the risk of an accident. The facility also failed to monitor the effectiveness of the interventions and modify the care plan as necessary, in accordance with current professional standards of practice for two of 17 sampled residents (Residents #201 and #254). The census was 67. Review of the facility's falls and fall risk management policy, last updated on 12/10/18, showed the following: -Based on previous evaluations and current data, the staff and IDT (interdisciplinary team) will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling; -The staff, with input of the IDT fall follow up review and attending physician, 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.

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional standards for two of six medication carts. The census was 67. 1. Observation on 4/1/21 at 8:28 A.M., of the second floor medication cart for A hall, showed the following: -An uncovered plastic medication cup filled with small pills. It had a handwritten label of Melatonin (a hormone primarily released by the pineal gland at night, and has long been associated with control of the sleep-wake cycle) 5 milligrams (mg) on the side of the cup; -One open vial of artificial eye drops, dated and labeled only with a resident's first name; -One open package of Breo Ellipta 100/25 (a prescription medication used to treat chronic obstructive pulmonary disease (COPD, a group of lung disease that block airflow and make it difficult to breathe)) and asthma (a condition causing difficulty in breathing), not in a pharmacy bag, labeled only with a resident's first name; -Two Basaglar insulin (a long acting insulin (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.

Based on observation, interview and record review, the facility failed to ensure staff who provided perineal care (cleansing between the legs and buttocks area) to dependent residents, followed acceptable hand hygiene infection control practices by failing to change gloves before applying barrier cream for one of two residents observed receiving personal care. (Resident #204). In addition, staff failed to clean the glucometer (machine used to check blood sugar levels) before and after use for Resident #252. The glucometer was used for multiple residents. The census was 67. 1. Review of the facility's Perineal Policy, updated on 12/10/15, showed the following: -Policy: It is the practice of the facility to provide perineal care to all incontinent residents as needed and during routine bath time in order to promote cleaniness and comfort, prevent infection to the extent possible and to prevent and assess for skin breakdown; -Further review of the policy failed to show documentation of when staff are to change gloves when performing perineal care. No handwashing/glove policy. 2. Review…

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