Estates Of St Louis, Llc, The

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to ensure six of six residents (Resident (R) 9, R13, R17, R28, R78, and R129) and their representatives reviewed for facility initiated emergent hospital transfer from a total sample of 24 were provided with written transfer/discharge notice that stated the reason for transfer, the place of transfer, and other information regarding the transfer. This failure had the potential to affect the residents and their Resident Representative (RR) by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired. Additionally, the Ombudsman was not notified of hospital transfers for three of six residents (R9, R13, R17). Findings include: Review of the facility policy titled, Admission, Transfer and Discharge Policy revised 08/24/24 indicated .The facility may transfer or discharge the resident in compliance with facility standards, and are as follows, but not limited to: 1. The resident's welfare…

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 six of six residents (Resident (R) 9, R13, R17, R28, R78, and R129) out of a sample of 24 residents who were reviewed for hospitalization were provided with a bed hold notice within 24 hours of emergent transfer to the hospital to include bed reserve payment. This failure increased the potential that residents would not know to request a bed hold and may be unable to return to the facility. Findings include: Review of the undated facility policy titled, Bed Hold Policy indicated, .This notification shall be given on admission to the facility, at the time of transfer to the hospital .Medicare does not pay for any type of bed hold. If the resident is discharged to the hospital, or goes out of the facility for over-night leave of absence, the bed may be held by paying the current room rate for the bed being served . 1.Review of R9's admission Record located in the Electronic Medical Record (EMR) under the Profile tab stated 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 interviews, record reviews, and facility policy reviews the facility failed to ensure that all Interdisciplinary Team Members (IDT) were participated in quarterly care conferences for 12 of 24 sampled residents (Resident (R) 9, R12, R13, R17, R25, R29, R32, R34, R36, R40, R57, and R73). This failure had the potential for the residents to have unmet care needs. Findings include: Review of the facility policy revised 08/24/24 stated, A care plan shall be used in developing the resident's daily care routine .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 .Care plan meetings will be held quarterly with the interdisciplinary team, resident and responsible party or guardian .A care plan conference will include the interdisciplinary team as applicable. Attendees will sign the care plan conference sign in sheet . 1.Review of R9's undated admission Record located in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to correctly issue Medicare Part A beneficiaries CMS-10055 (Skilled Nursing Advanced Beneficiary Notice (SNFABN) when resident completed therapy or skilled nursing services for two of three residents (Resident (R) 9 and R68) reviewed for beneficiary notices. This failure had the potential of a resident or responsible party to not make an informed decision related to continuing to receive Medicare A services, by having the facility continue services and bill Medicare A, continue the services, and bill the resident, or not receive the services. Findings include: Review of the undated facility policy titled ABN / NOMNC Policy provided by the facility stated, Skilled nursing facilities must deliver a completed copy of the Advance Beneficiary Notice of Non-Coverage (ABN) and Medicare Non-Coverage (NOMNC) to beneficiaries/enrollees receiving covered skilled nursing services. The ABN/NOMNC must be delivered at least 2 calendar days…

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 grievances were resolved in a timely manner for one of 24 sampled residents (Resident (R) 23). This failure has the potential to affect the current residents and/or their family members by not having grievances resolved in a timely manner. Findings include: Review of the policy titled Grievance Policy and Procedure dated 06/15/24 indicated our facility investigates all grievances and complaints filed within the facility in a timely manner .(3) if a grievance is pertaining to an alleged violation of resident rights, as necessary, the Administrator must be notified, by the Social Service Worker, so that immediate action can be taken to prevent further potential violations of any resident right. Review of the admission Packet provided by the facility indicated our facility investigates all grievances and complaints filed within the facility in a timely manner. The Administrator has assigned the responsibility of investigating…

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 review of facility's policy, the facility failed to timely report a resident to resident alleged physical altercation to the State Agency (SA) involving two residents (Resident (R)13 and R17) of 16 residents reviewed for reporting alleged allegations of abuse. This had the potential for continued resident to resident altercations for the two residents. Findings include: Review of the facility policy titled, Abuse, Neglect and Exploitation Policy revised 04/08/24 revealed, .1. The Abuse Coordinator in the facility is the Administrator or facility appointed designee. Report allegation or suspected abuse, neglect or exploitation immediately to the Administrator, Other officials in accordance with State Law (this includes law enforcement officials), and State Survey and Certification agency through established procedures. 1.Review of R13's undated admission Record located in the Electronic Medical Record (EMR) under the Resident tab indicated the resident was admitted 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review, the facility failed to complete a thorough investigation for and resident to resident alleged altercation for two residents (Resident (R) R13 and R17) out of 16 sampled residents reviewed for abuse. This failure had the potential to place the residents to future potential altercations. Findings include: Review of the facility policy titled Abuse, Neglect and Exploitation Policy provided by the facility and revised on 04/08/24 stated, .When suspicion of abuse .occur, it must be communicated to the facility's Administrator, Department Head, or Supervisor and the Administrator and/or designee must initiate an investigation Components of the investigation may include: .Interview all witnesses separately. Include roommates, residents in adjoining rooms, staff members in the area and any noted visitors in the area. Obtain witness statements, according to appropriate policies. All statements should be signed and dated by the person making the statement. Document 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 interview, record review, and policy review, the facility failed to ensure that four (Residents (R)9, R19, R32, and R37) out of 24 sampled residents had an accurate Minimum Data Set (MDS) assessment. Failure to code the MDS correctly could potentially lead to inaccurate federal reimbursements and inaccurate assessment and care planning of the resident. Findings include: Review of the undated policy titled MDS (Minimum Data Set) provided by the facility stated .The RAI (Resident Assessment Instrument) Manual serves as the policy by which the facility follows the process of completing MDS assessments. 1.Review of R9's undated admission Record located in the Electronic Medical Record (EMR) under the Profile tab indicated she was re-admitted to the facility on [DATE] with a primary diagnosis of heart failure. Review of R9's MDS located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 07/13/24 with a Brief Interview for Mental Status (BIMS) score of not assessed. R9 was coded as 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 observation, interview and record review, the facility failed to ensure that residents receive proper treatment to maintain vision when staff failed to reschedule transportation arrangements for one sampled resident (Resident #500) out of 13 sampled residents, who had an eye appointment and was recommended to have retina surgery then cataract surgery. The resident missed the appointment when transportation did not show up and staff failed to reschedule the appointment after it was missed. The facility also failed to follow-up with the resident's routine eye appointment. The census was 77. During an interview on 2/7/25 at 12:50 P.M., the transportation policy was requested. The Administrator said there is no policy. There is just a protocol that staff follow. Review of Resident #500's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/9/25, showed: -Severe cognitive impairment; -Vision: Adequate-Sees fine detail, including regular print in newspaper/books; -Diagnoses included diabetes, dementia, schizophrenia, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to ensure that one of 39 residents (Resident (R)13) reviewed for smoking wore a smoking apron while smoking. This failure placed R13 at risk for injury. Findings include: Review of the facility policy titled Smoking Policy last reviewed on 10/12/24 revealed .Residents who are identified as 'supervised smokers' will be monitored by facility staff. If a resident identifies as a supervised smoker who requires smoking assistance (i.e., smoking aprons .) will be addressed and care planned for preventative measures to ensure residents safety . Review of R13's undated admission Record located in the Electronic Medical Record (EMR) under the Resident tab indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with a primary diagnosis of dementia. Review of R13's quarterly Minimum Data Set (MDS) under the MDS tab in the EMR had an Assessment Reference Date (ARD) of 10/16/24 indicated 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, record review, and facility policy review, the facility failed to provide oxygen services that included cleaning of the oxygen concentrator for one of one residents (Resident (R)13) reviewed for oxygen therapy. This failure had the potential for the concentrator to not remove all contaminated air and provide adequate oxygenation to the resident. Findings include: Review of the facility's policy titled Oxygen Supply Policy revised 07/15/24 stated This facility will maintain oxygen device supplies in a clean status, ensuring proper labeling and replacement of supplies as needed/per physician's orders . Review of R13's undated admission Record located in the Electronic Medical Record (EMR) under the Resident tab indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with a primary diagnosis of dementia. Review of R13's quarterly Minimum Data Set (MDS) under the MDS tab in the EMR had an Assessment Reference Date (ARD) of 10/16/24 indicated the…

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

Based on observation, interview, and review of the facility's policy, the facility failed to maintain the cleanliness of two of the two medication rooms. The failure has the potential to contribute to the pest infestation. Additionally, the facility failed to ensure medication refrigerator temperature logs were maintained in two of the two medication rooms. Also, the facility failed to ensure that expired medications and syringes were removed from the medication cart. Findings include: A review of the facility's policy titled, Storage and Labeling of Medication, with a revision date of 01/01/24, guides the staff as follows: Orally administered medications are kept separate from externally used medications and treatments such as suppositories, ointments, creams, vaginal products, etc. Eye medications are stored separately per facility policy Outdated, contaminated, or deteriorated medications and those in containers that are correct, soiled, or without secure closures, or immediately removed from the inventory, disposed of in accordance to the procedure for medication disposal, 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.

Based on interview and record review, the facility failed to ensure dental care and services were provided to one sampled resident who requested dental services (Resident #500) out of 13 sampled residents. The census was 77. During an interview on 2/7/25 at 12:50 P.M., the transportation policy was requested. The Administrator said there is no policy. There is just a protocol that staff follow. Review of Resident #500's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 1/9/25, showed: -Severe cognitive impairment; -No dental issues present; -Diagnoses include diabetes, dementia, schizophrenia, and anxiety. Review of the resident's provided dental assessments, showed: -Oral assessment, 5/8/24, no natural teeth or tooth fragments (edentulous): Fully edentulous, no appliances. No pain, resident is interested in getting full dentures if he/she is eligible. Stated he/she has never had them before and he/she currently sticks to softer foods; -Oral assessment, 6/5/24, no natural teeth or tooth fragments (edentulous). Fully…

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, with a diagnosis of Alzheimer's disease and known behaviors, attained or maintained his/her highest practicable, mental, and psychosocial well-being (Resident #1). Staff failed to provide increased behavioral monitoring and failed to update the resident's care plan with identified triggers, personalized interventions, and/or meaningful activities focused on the resident's preferences which resulted in a resident-to-resident altercation. The census was 78. Review of the facility's Supervision and Management of Residents with Behaviors policy, reviewed 1/24/24, showed: -Policy: To provide support to team members to maintain safety and security when providing care to our residents who may exhibit behaviors, while treating our residents with dignity, respect and compassion; -Protocol: -De-escalation education will be provided to team members; -The best way to manage resident behaviors is to provide care in a dignified, respectful 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 staff completely and accurately documented neurological checks (neuro checks, assessing mental status and level of consciousness, pupillary response, motor strength, sensation, and gait) for one resident (Resident #2). The sample was three. The census was 84. Review of the facility's Fall Policy, dated 12/1/19, showed the following: -Policy: The staff will identify any resident falls and assess resident's condition and cause of fall. Interventions related to the resident's specific risks and causes will be put in place to prevent the resident from falling and to try to minimize complication from falling; -Assess the resident for changes in level of consciousness and signs or symptoms of injury. Assess the resident immediately after the fall, then frequently throughout the shift. Assessment should continue for a minimum of 72 hours. -Notify the primary care physician (PCP) immediately after the fall and follow the physician's orders related to fall. If the resident is unconscious, has a significant injury or has 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 interview and record review, the facility failed to report an allegation of abuse involving one resident (Resident #1) to law enforcement as required. The facility failed to report an allegation staff sold the resident cocaine and Fentanyl (used to treat pain, has a high risk for addiction and dependence, can cause respiratory distress and death when taken in high doses or when combined with other substances, especially alcohol or other illicit drugs such as cocaine). In addition, the facility's Abuse and Neglect policy failed to include guidance to staff on when law enforcement should be notified. The facility census was 84. Review of the facility's undated Abuse, Neglect and Exploitation policy, 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…

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

Based on interview and record review, the facility failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate certification, when a consultant Registered Dietician (RD) was not employed full-time with the facility. This had the potential to affect all residents who consume meals at the facility. The census was 80. 1. Review of the facility's Director of Food Service's job requirements, showed the following: - Qualifications: Requires a High School diploma or General Educational Development (GED), Prefer a Dietetic Technician, registered by the American Dietetic Association. Or, a Certified Dietary Manager, as certified by the Dietary Manager's Association. Or, a graduate of an associate or baccalaureate degree program in foods and nutrition or food service management 2. During an interview on 8/24/23 at 10:46 A.M. the Administrator said the following: -The facility does not have a full time Registered Dietitian (RD). The contracted RD comes out to the facility at least monthly; -The Dietary Manager has been employed with the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to prevent mice, flies and gnats in common areas and resident rooms (Residents #58, #3, #40, #73, #48, and #36). The census was 80. Review of the facility's Pest Control policy, revised 3/2022, showed: -Policy: This facility will ensure facility remains clean and free from pests; -Policy explanation and compliance guidelines included; -Daily cleaning of facility will be monitored; -Monthly contracted pest control company will treat inside and outside of facility. 1. Review of the facility's contracted pest control company pest sighting log, showed: -3/27/23 exterior power spray; -4/11/23, regular service; -5/9/23, regular service; -6/6/23, regular service; -7/11/23, regular service; -8/2/23, regular service; -No documentation of specific areas treated, pest sightings, or recommendations. 2. Review of the facility's resident council meeting minutes, dated 7/25/23, showed: -Residents in attendance:…

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 all resident personal funds in excess of $100.00 were in an interest bearing account. The facility failed to ensure resident requests for less than $100.00 ($50.00 for Medicaid residents) are honored within the same day by not providing residents access to their trust account during consistent hours and on the weekends (Residents #3, #40, #34, #49, #50, #51, #60, and #41). These deficient practices affected all the residents who had a resident trust account. The census was 80. Review of the facility's Management/Protection of Resident Funds policy, updated 1/25/23, showed: -All residents' personal funds shall be deposited in a passbook type interest bearing account and shall be subject to the terms and conditions imposed by the financial institution where such account is located; -The facility will maintain resident funds that do not exceed $50.00 in a non-interest bearing account or petty cash fund; -The facility will have posted…

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 quarterly statements to residents and/or their representatives (Residents #3, #40, #34, #51, #50, #60, #39 and #49). This deficient practice affected 61 residents whose funds were handled by the facility. The census was 80. Review of the facility's Management/Protection of Resident Funds policy, updated 1/25/23, showed: -A record of transactions regarding the resident's funds shall be maintained by the facility in accordance with the generally accepted accounting principles; -The resident shall have reasonable access, upon request, to the above records and shall receive an itemized quarterly statement of his/her account. 1. Review of the facility's resident trust transaction history, showed the facility holds funds for 61 residents, including Residents #3, #40, #34, #51, #50, #60, #39 and #49. 2. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/13/23,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain clean privacy curtains and provide bed linen for four sampled residents (Residents #15, #16, #48 and #64) and failed to ensure one resident's room was free from mouse droppings (Resident #58). The sample was 18. The census was 80. Review of the facility's Maintaining a Safe, Clean, Comfortable and Homelike Environment policy, revised 5/22/22, showed the following: -Policy: This facility will accommodate, to the extent possible, a personalized, homelike environment that recognizes the individuality and autonomy of each resident, while maintaining the safety of all residents and staff. -Policy Explanation and Compliance Guidelines: -Minimize odors by disposing of soiled linens promptly and reporting lingering odors and bathrooms needing cleaning to the Housekeeping Department; -Report any furniture in disrepair to Maintenance promptly; -Maintain a clean, comfortable and homelike environment (i.e., ceiling tiles, wallpaper, floor…

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 information to the residents on how to file a grievance or complaint. This had the potential to affect all residents at the facility. The census was 80. Review of the facility's admission Agreement, provided to residents upon admission, showed: -Residents' rights to voice grievances; -The residents may voice concerns and problems, along with recommended changes, to facility staff or outside representatives. Owners and staff of facilities are prohibited by law from retaliating if you complain. The residents should speak with the Director of Nursing or the Administrator of the facility if you encounter problems requiring immediate attention. For non-emergencies, speak to the resident council or Ombudsman; -Instructions on filing a grievance; -The facility investigates all grievances and complaints filed within the facility in a timely manner. The Administrator has assigned the responsibility of investigating grievances and complaints to the Social Service Department. Any resident, visitor, vendor, or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure each resident received adequate assistance to prevent accidents by not using a gait belt during transfers (Residents #36, #73, #58 and #31). The facility failed to document a resident's fall in the resident's progress notes (Resident #36). In addition, the facility failed to document fall prevention interventions on the resident's care plan and ensure the resident was able to reach his/her call light (Resident #59). The sample was 18. The census was 80. Review of the facility's Fall policy, reviewed 12/1/22, showed: -The staff will identify any resident fall and assess resident's condition and cause of fall; -Interventions related to the specific risks and causes will be put in place to prevent the resident from falling and try to minimize complication from falling; -Assess the resident for changes on level of consciousness and signs or symptoms of injury; -Assess the resident immediately after the fall, then frequently throughout…

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 eight consecutive hours a day, seven days a week. The census was 80. Review of the facility's Facility Assessment Tool, updated 7/16/23, showed: -Average daily census: 80-85; -Staff type: Identify the type of staff members, other health care professionals, and medical practitioners that are needed to provide support and care for residents; -Nursing Services: Director of Nurses (DON), Assistant Director of Nurses (ADON), Minimum Data Set (MDS) Coordinator, Infection Control and Prevention, RN, Licensed Practical Nurse (LPN), Certified Medication Technician (CMT), and Certified Nurse Aide (CNA); -Staffing plan: Based on the resident population and their needs for care and support, describe the general approach to staffing to ensure sufficient staff to meet the needs of the residents at any given time; -Licensed Nurses (LN) providing direct care: One to two per shift; -Other nursing personnel (e.g., those with administrative duties): one for day; -The facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe and sanitary environment and to help prevent the transmission of infections. Staff failed to follow proper hand hygiene during perineum care (peri-care, cleansing of the genitals and buttocks area) observed for three out of three residents (Residents #77, #73 and #58). Additionally, the facility failed to follow their communicable disease policy by failing to ensure newly admitted residents received the Mantoux tuberculin skin test (TST, used to test for latent tuberculosis (TB) infection) two step as required for five out of five sampled residents (Residents #31, #30, #45, #63 and #41). The census was 80. Review of the facility's Peri-Care policy, updated 6/13/23, showed: -It is the practice of this facility to provide peri-care to all incontinent residents as needed and during routine bath time in order to promote cleanliness and comfort, prevent infection to the extent…

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 two residents reviewed who received Medicaid benefits (Residents #17 and #1). The census was 80. Review of the facility's Management/Protection of Resident Funds policy, updated 1/25/23, showed: -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 SSI resource limit for one person, and 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 #17's trust account, showed: -In August 2022, he/she had $10,108.45 in his/her account; -In September 2022, he/she had $10,108.45 in his/her account -In October 2022, he/she had $10,110.50 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 observation, interview, and record review, the facility failed to maintain privacy and confidentiality of personal and medical records for seven residents (Residents #78, #53, #63, #71, #29, #46 and #30). The census was 80. Review of the facility's Charting and Documentation policy, undated, showed: -Policy: All services provided to the resident, or any changes in the resident's medical or mental condition will be documented in the resident's medical record; -Information documented in the resident's medical record is confidential and may only be released in accordance with state law and facility policy. 1. Review of Resident #78's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/10/23, showed: -Moderate cognitive impairment; -Diagnoses included dementia, depression, adjustment disorder, and schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves); -Antipsychotic medication received seven out of seven…

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 conduct a complete and thorough investigation of an allegation of staff to resident abuse and failed to suspend the staff accused of threatening a resident, pending an investigation in accordance with their policy. This affected one of eighteen sampled residents (Resident #15). The census was 80. Review of the facility's Abuse, Neglect and Exploitation policy, 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; -Investigation of Alleged Abuse, Neglect, and Exploitation: When suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect…

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 professional standards of practice by not notifying the physician when a resident's blood sugar was elevated, when the resident refused insulin injections, and to have interventions in place for refusals of medications and treatments for one resident (Resident #15). In addition, the facility failed to obtain a physician's order for blood sugar checks prior to administering Levemir (long acting insulin) to one resident (Resident #36). The sample was 18. The census was 80. Review of the facility's Refusal of Treatment policy, updated 5/25/22, showed: -Our facility shall honor a resident's request not to receive medical treatment as prescribed by his or her physician, as well as, care routines outlined on the resident's assessment and plan of care; -The resident is not forced to accept any medical treatment and may refuse specific treatment even though it is prescribed by a physician; -Treatment is defined as care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents were showered routinely and in clean clothing (Residents #41 and #45) and residents received proper nail care (Residents #16 and #64). The census was 80. Review of the facility's Activities of Daily Living policy, dated 6/22/20, showed: -Purpose: 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. -Policy: Residents will be provided with care, treatment and services to ensure that their ADLs do not diminish unless the circumstances of their clinical condition demonstrate that diminishing ADLs are unavoidable. The existence of a clinical diagnosis and/or condition does not alone justify a decline in the resident's ability to perform…

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 their skin care policy, resulting in an untreated non-pressure wound for one sampled resident (Resident #31). The sample was 18. The census was 80. Review of the facility's Skin Care Protocol, updated on 1/12/21, showed: -Policy: To ensure that all residents' skin is monitored and assessed to be proactive in preventing skin integrity issues; -Procedure: Certified Nurse Assistants (CNA) will perform a visual assessment of a resident's skin when giving the resident a shower. Immediately report any abnormal looking skin to the charge nurse. Document findings on the Shower Sheet and turn form into the charge nurse. Charge nurse will place their signature on the Shower Sheet after assessing the resident's skin issues. Charge nurse will notify the Primary Care Physician (PCP) with changes and document any new orders and interventions. The Charge nurse will forward any problems to the Director of Nursing (DON) or designee for review. If DON or designee is on duty during any skin issues found, notify…

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 35 opportunities observed, four errors occurred resulting in an 11.43% error rate (Residents # 56, #57, and #78). The census was 80. Review of the facility's Administration Medication policy, updated 1/12/21, showed: -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; -Medications are to be administered within one hour of their prescribed time, unless otherwise specified; -The individual administering the medication must check the label to verify the right resident, right medication, right dosage, right time, and right route before giving the medication; -If a medication is withheld, refused or given at a time other than the scheduled time the individual will document the rationale; -It is best practice to document medication administration in the moment, prior to moving on to the next resident; -If a medication is missing 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 medical records were accurately documented in accordance with acceptable professional standards of practice when staff inaccurately documented medications were administered (Residents #56, #57 and #78). The sample was 18. The census was 80. Review of the facility's Charting and Documentation policy, undated, showed: -All services provided to the resident, or any changes in the resident's medical or mental condition will be documented in the resident's medical record; -All observations, medications administered, and services performed will be documented in the resident's medical record; -All incidents, accidents, or changes in the resident's condition must be recorded; -Documentation of procedures and treatments will include care specific details at a minimum, will include: -Date and time procedure/treatment was provided; -Name and title of the individuals that provided care; -Assessment data and/or any unusual findings obtained during the procedure treatment; -How the resident tolerated the procedure…

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

Based on interview and record review, the facility failed to ensure the resident trust account statements were accurately reconciled for 12 of 12 months reviewed. The census was 82. Review of the last 12 months of the resident trust account, showed: -January 2019, ending bank balance: $13,429.78, outstanding checks/transfers: $7,891.63, cash on hand: $625.32, adjustments: $3,020.94 (nothing to show what the adjustments were for); ending trust report balance: $9,184.41, difference $0.00. During an interview on 2/10/19 at 12:20 P.M., the business office manager (BOM) said she does not do the reconciliation, it comes from the corporate office. During an interview on 2/10/19 at 1:16 P.M., the corporate office business manager said the adjustments are made at the end of the month. If it is a negative adjustment, then it could be money that did not transfer over and the money would be put in the trust account in a couple of months. The adjustment amount that is added in, is the ending bank balance minus the outstanding checks/transfers and then cash on hand is added in. If it does 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete and send a Third Party Liability (TPL) form (a form which is sent to MO Healthnet which gives an accounting of the remaining balance of that resident's funds in the resident trust account), which is required to be sent within 30 days after the death, for seven of seven residents who expired in the facility the past year and had money in their trust account (Residents #400, #401, #402, #403, #404, #405, and #406). The census was 82. Review of seven residents trust information, who expired in the past year, showed the facility did not notify the TPL unit. During an interview and record review on [DATE] at 2:15 P.M., the business office manager (BOM) provided information regarding residents who expired in the past year. The forms showed they notified Social Security Administration that the residents had expired. The facility provided no information that they notified the TPL unit of any money that remained in the resident trust. The BOM did 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete comprehensive resident assessments using the Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, within 14 calendar days after admission to the facility, upon a significant change in the resident's status, and not less than every twelve months, for six out of 46 sampled residents (Residents #154, #34, #9, #14, #202 and #204). The census was 82. 1. Review of Resident #154's medical record, showed: -admitted to the facility on [DATE]; -readmitted to the facility on [DATE]; -An entry MDS completed on 11/9/19; -No comprehensive MDS completed, as of 2/11/20. 2. Review of Resident #34's medical record, showed: -admitted to the facility on [DATE]; -A quarterly MDS completed on 9/26/19; -No entry or admission MDS completed between 6/18/19 and 9/26/19. 3. Review of Resident #9's medical record, showed: -admitted to the facility on [DATE]; -An annual comprehensive MDS completed on 11/14/18; -Quarterly MDSs…

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 complete quarterly review assessments in a timely manner, no less than once every three months, using the Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, for 15 out of 46 sampled residents (Residents #102, #22, #30, #31, #34 #10, #11, #8, #38, #103, #253, #41, #37, #44 and #204). The census was 82. 1. Review of Resident #102's medical record, showed: -admitted to the facility on [DATE]; -An admission MDS completed on 7/23/19; -No quarterly MDS completed, as of 2/11/20. 2. Review of Resident #22's medical record, showed: -admitted to the facility on [DATE]; -An entry MDS completed on 8/8/19; -No quarterly MDS completed, as of 2/11/20. 3. Review of Resident #30's medical record, showed: -admitted to the facility on [DATE]; -An entry MDS completed on 8/21/19; -No quarterly MDS completed, as of 2/11/20. 4. Review of Resident #31's medical record, showed: -admitted to the facility on [DATE]; -An admission 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement a person centered care plan that addressed the medical, physical and psychosocial needs of two residents (Residents #202 and #31). The facility also failed to address one resident's nutritional needs, including a significant weight loss (Resident #16) and another resident (Resident #102), who received hospice services. The census was 82. 1. Review of Resident #202's Baseline Care Plan, dated 11/15/19, showed -admitted on [DATE]; -Diagnoses included left below knee amputation, impaired brain function and history of alcohol abuse; -Regular diet. Provide diet as ordered and provide supplements. Further review of the resident's medical record, showed no comprehensive care plan completed in the resident's electronic or paper medical record. During an interview on 2/10/20 at 10:28 A.M., Assistant Director of Nursing (ADON) B said the resident had a comprehensive care plan completed, but it was in an electronic medical…

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

Based on observation, interview and record review, the facility failed to ensure medication error rates are not 5 percent or greater. Out of 30 opportunities observed, there were two errors, resulting in a 6.67% medication error rate (Resident #155). The census was 82. Review of the facility's policy on the Administration of Eye Drops, updated 1/6/19, showed: -Policy: Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medication do so only after they have familiarized themselves with the medications; -#5. Instruct resident to close eyes slowly to allow for even distribution over the surface of the eye and apply gentle pressure to the tear duct for one minute or by gently closing the eye for 3 minutes. Review of Resident #155's physician's order sheet (POS), dated 2/1/20 through 2/29/20, showed: -Brimonidine tartrate (eye medication used to treat glaucoma) 0.15%, one drop both eyes three times per day; -Dorzolamide (eye medication used to treat…

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 complete significant change Minimum Data Sets (MDS), a federally mandated assessment instrument completed by facility staff, for two residents enrolled in hospice programs (Residents #102 and #12). The census was 82. 1. Review of Resident #102's medical record, showed: -admitted to the facility on [DATE]; -An admission MDS completed on 7/23/19; -admitted to hospice on 11/18/19; -No significant change MDS completed to reflect admission to hospice. 2. Review of Resident #12's medical record, showed: -admitted to the facility on [DATE]; -admitted to hospice on 1/10/20; -No significant change MDS completed to reflect admission to hospice. 3. During an interview on 2/11/20 at 12:15 P.M., the Assistant Director of Nurses (ADON) said the facility hired a new employee to complete and submit MDSs in January 2020. The person who previously held the MDS position had been completing the MDSs, but not electronically transmitting them. All MDSs should be transmitted…

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 complete and electronically transmit resident Minimum Data Sets (MDS), a federally mandated assessment instrument completed by facility staff, for six out of 46 sampled residents (Residents #12, #6, #16, #34, #252, and #42). The census was 82. 1. Review of Resident #12's medical record, showed: -admitted to the facility on [DATE]; -discharged from the facility, return not anticipated, on 11/26/19; -No discharge MDS completed or transmitted. 2. Review of Resident #6's medical record, showed: -admitted to the facility on [DATE]; -discharged from the facility, return not anticipated, on 12/18/19; -No discharge MDS completed or transmitted. 3. Review of Resident #16's medical record, showed: -admitted to the facility on [DATE]; -A quarterly MDS completed 5/23/19; -A significant change MDS, completed on 10/15/19, not transmitted. 4. Review of Resident #34's medical record, showed: -admitted to the facility on [DATE]; -An entry MDS completed on 6/18/19, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure all physician's orders were followed by not checking blood pressures and pulses as ordered prior to administering medication and ensuring a timely response to a dietary recommendation for a resident with weight loss as ordered for three of 46 sampled residents (Residents #152, #155 and #202). The census was 82. 1. Review of Resident #152's physician's order sheet (POS), dated 1/1/20 through 1/31/20, showed: -Amlodipine (medication used to treat high blood pressure) 10 (milligram) mg one tablet by mouth once daily. Hold if systolic (top number of the blood pressure) blood pressure is less than 100 or pulse less than 60; -Check pulse in the morning and record; -Check blood pressure in the morning and record. Review of the resident's medication administration record (MAR), dated 1/1/20 through 1/31/20, showed: -Front of MAR: Amlodipine 10 mg once daily. Hold if systolic less than 100 or pulse less than 60; -Staff documented pulse as 54…

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.