Hillside Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were allowed to exercise their right to choose their attending physician when the facility discontinued services with Physician RR and failed to permit Physician RR to continue providing care within the facility, resulting in residents being required to transition to a different physician for two residents (Residents #133 and #139). The sample size was 33. The census was 149. Review of the facility's undated admission Agreement, showed:-Resident rights: Facility has delivered, and Resident acknowledges receipt of a document entitled ''Nursing Home Resident Rights that describes Resident's rights at Facility. Resident also acknowledges that Facility has orally explained these rights in terms Resident can reasonably be expected to understand. The rights of Resident do not include any proprietary, legal or equitable interest in the properties of Facility;-Selection of Healthcare Professionals by Resident: Resident may select, or have…

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

Based on interview and record review, the facility failed to routinely notify residents receiving Medicaid benefits when the amount in the resident's account was within $200.00 of the resource limit for seven residents (Resident #117, #66, #55, #1, #108, #120, and #155). The facility identified 124 residents with a resident trust account. The census was 149. Review of the facility's Resident Trust policy, dated 3/1/17, showed the resident trust clerk must monitor account balances. Missouri Medicaid residents are allowed to keep only a total of their state's allowable limit (Missouri is $6068.80, effective 7/1/2025) in non-exempt resources. Any Medicaid resident who is within $200.00 of these allowed amounts should be notified in writing that he/she is within $200.00 of the allowable non-exempt resource limit set forth and may lose their eligibility if they accumulate excess funds. The Administrator and facility Social Worker should be advised of all account balances at this limit for follow up. 1. Review of Resident #117's balance notification letters, dated May, July, August, 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 Base on interview and record review, the facility failed to review and administer hospital admission orders for one resident (Resident #39), when staff failed to administer an ordered antibiotic to treat the resident's urinary tract infection (UTI). Additionally, staff failed to implement a physician's order for a protective boot for one resident (Resident #16) and failed to follow up on physician's referrals for skilled therapy for two residents (Residents #16 and #90). The sample was 33 and the census was 149. Review of the facility's Transcription of Orders/Following Physician's Orders policy revised on 05/24, showed: The purpose of this policy is to outline procedures in accurately transcribing physician's orders and to ensure that all physicians' orders are followed. To ensure a process is in place to monitor nurses in accurately transcribing and following physician's orders. Upon receiving a physician's order via telephone, fax, written order, verbal order, transcribed order or other, it will be documented…

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 requiring assistance with activities of daily living (ADLs) received necessary services when staff left one resident soiled for an extended period (Resident #155), and failed to provide hygiene assistance for one resident (Resident #6), and supervision during meals for one resident (Resident #110). The sample was 33. The census was 149. Review of the facility's ADL policy, dated 5/18/24, showed:-Purpose: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable;-Cares and services will be provided for the following ADLs;--Bathing, dressing, grooming and oral care;--Transfer and ambulation;--Toileting;--Eating to include meals and snacks. 1. Review of Resident #155's quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by the facility staff,…

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

Based on observation, interview and record review, the facility failed to provide care to prevent pressure ulcers for one resident (Resident #90). Staff did not provide a treatment to the resident's wound as the physician ordered and left the wound exposed to air. Staff also did not update the resident's care plan after they discovered the resident had a pressure wound. The sample size was 33. The census was 149. Review of the facility's Pressure Ulcer Management policy dated 05/24, showed:-Purpose: The facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries;-Definitions: Pressure Ulcer/Injury refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device;-Policy: Assessment of Pressure Injury Risk:---Licensed Nurse (Registered Nurse (RN) and Licensed Practical Nurse (LPN) will conduct a pressure injury risk…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility staff failed to use a gait-belt (specialized device utilized to assist during transfers) during a transfer for two residents (Resident #143 and #86 ). The sample size was 33. The census was 149. Review of the facility's Gait Belt policy, dated 6/23, showed:-Purpose: The purpose of this policy is to ensure precautionary and safe measures are taken during the application and use of gait belts;-Procedure:--Safe usage of a gait belt can prevent potential risk of injury to residents that could be caused by pulling on their arms, shoulders and wrists during ambulation, transfers or repositioning;--Safety Measure: Never transfer any resident by lifting them under their arms. Avoid the axillary area on the resident as this has the potential to cause nerve damage, shoulder dislocation, bruising, pain and fractures;--Never attempt to transfer a resident independently that cannot bear weight. A mechanical device/lift must be used in the plan of care for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a pre-assessment and post assessment communication form to the dialysis center for two out of two dialysis residents sampled (Resident #2 and Resident #5) receiving hemodialysis (a treatment to clean the body's blood supply of impurities). The sample size was 33. The census was 149. Review of the facility's Dialysis policy, last revised 3/18/22, showed:-Purpose:--Ensure that the residents who require dialysis receive such services as ordered by physician;--The facility will ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences;--The facility will ensure that each resident receives care and series for the provision of hemodialysis consistent with professional standards of practice including:---Ongoing assessment of the resident's condition and monitoring for complications before 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 one resident (Resident #12) of 33 sampled residents received follow-up trauma-informed care after a shooting incident occurred at the facility. The census was 149. Review of the facility's behavioral health services policy, dated 10/31/24, showed:-Purpose: It is the policy of this facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning;- The facility will consider the acuity of the resident population. This includes residents with mental disorders, psychosocial disorders, or substance use disorders (SUDs), and those with a history of trauma and/or post-traumatic stress disorder ((PTSD), a mental health condition triggered by experiencing or witnessing terrifying events), as reflected in the facility assessment;-The facility will ensure that a resident who, upon admission was not assessed or diagnosed with a mental or psychosocial adjustment difficulty or a documented history of…

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

Based on observation, interview and record review, the facility failed to ensure medication was stored properly by failing to ensure medications in the 300 south unit medication refrigerator were secured behind a lock. The sample size was 33. The census was 149. Review of the medication storage policy, dated 5/18/24, showed:-Purpose: It is the policy of this facility to ensure all medications housed on our premises will be stored in the medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Observation on 04/20/26, of the 300 south medication storage room, showed:-At 12:17 P.M., the door to the medication storage room was open with no staff present. The refrigerator was unlocked. Six vials of Haloperidol (antipsychotic medication) were in the refrigerator in a Ziplock bag, along with two boxes each containing four Trulicity insulin pens (injectable medication for type two diabetes);-At 12:21 P.M., the medication storage room door remained open with 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure dental services were provided to two of 33 sampled residents (Residents #12 and #113). The census was 149. Review of the facility's Dental Services policy, dated 6/26/24, showed:-Purpose: It is the policy of this facility to assist residents in obtaining routine (to the extent covered under the state plan) and emergency dental care;-Dental services: The Social Services Director maintains contact information for providers of dental services that are available to facility residents at a nominal cost. The facility will, if necessary or requested, assist the resident with making dental appointments and arranging transportation to and from the dental services location;-Documentation: All actions and information regarding dental services, including any delays related to obtaining dental services, will be documented in the resident's medical record. 1. Review of Resident #12's quarterly Minimum Data Set (MDS), a federally mandated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow acceptable infection control standards during perineal care (peri-care, cleaning of the genitals and rectal area) for two residents (Resident # 155 and Resident #108). The sample size was 33. The census was 149. Review of the facility's Peri Care policy, last revised on 6/29/23, showed:-Purpose: The purpose for this policy is to ensure that the female and male resident genital area is kept clean and proper techniques are used to prevent skin break down, infections or any other impairments that can be caused from not using proper aseptic (non-sterile) technique;-Procedure for giving peri-care to the male resident:--Gather necessary equipment;--Wash our hands;--Put on gloves;--Explain what you are going to do;--Provide privacy;--Resident should be back-lying or side-lying position;--Fill basin with warm water;--Expose perineal area; Using a circular motion, gently wash the penis by lifting it and cleaning from the tip downward; Rinse…

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 the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. This had the potential to affect all residents of the facility. The sample was 8. The census was 147.Review of the facility's Sufficient Staffing Policy, dated February 2023, showed the following:-Purpose: It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility's census, acuity and diagnoses of the resident population will be considered based on the facility assessment;-Policy:-The facility is required to provide licensed nursing staff 24 hours a day, 7 days a week;-Except when waived, the facility must use the services of a Registered Nurse for at least 8 consecutive hours a day, 7 days a week. Review of the facility's staffing sheets for March 2026, showed the following:-On 3/1/26, no RN scheduled;-On 3/7/26, no RN…

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 to the Department of Health and Senior Services (DHSS) as required within a two-hour timeframe following a physical altercation between two residents (Residents #1 and #2). The sample was eight. The census was 147. Based on interview and record review, the facility failed to report an allegation of abuse to the Department of Health and Senior Services (DHSS) as required within a two-hour timeframe following a physical altercation between two residents (Residents #1 and #2). The sample was eight. The census was 147. Review of the facility's Abuse and Neglect policy, dated 6/12/24, showed the following:-Purpose: It is the policy of this facility to report all allegations of abuse, neglect, exploitation or mistreatment, including injuries of unknow sources and misappropriation of resident property are reported immediately to the Administrator for the facility and to other appropriate agencies in accordance with current state…

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 thoroughly investigate an allegation of abuse involving a physical altercation between two residents (Residents #1 and #2). The sample was eight. The census was 147. Review of the facility's Abuse and Neglect policy, dated 6/12/24, showed the following:-Purpose: It is the policy of this facility to report all allegations of abuse, neglect, exploitation or mistreatment, including injuries of unknow sources and misappropriation of resident property are reported immediately to the Administrator for the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed time frames;-Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Instances of abuse of all residents, irrespective of any mental or physical condition,…

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 F684 cited under Event ID 4F7E12 Based on observation, interview and record review, the facility failed to obtain physician orders and monitor a wound identified by staff for one resident (Resident #27). The census was 145. Review of the Wound Management Policy, revised 10/24/22, showed: -Purpose: provide a system for the treatment and management of residents with wounds including pressure and non-pressure ulcers; -Definitions: Diabetic Neuropathic Ulcer: requires that the resident be diagnosed with diabetes mellitus and have peripheral neuropathy. The diabetic ulcer characteristically occurs on the foot; -Procedure: Assessment: -A licensed nurse will perform a skin assessment upon admission, readmission, weekly, and as needed for each resident; -Upon identification of a wound the licensed nurse will: -Measure the wound (length, width and depth); -Initiate a wound monitoring record sheet: -A wound monitoring record will be completed for each wound; -If the wound monitoring record is not used, documentation will be recorded within the medical record which may include nursing…

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 policies for Transfer and Discharge & Elopement and Wandering for one resident (Resident #1), when facility staff failed to provide written discharge notice to the resident and his/her legal guardian- when the resident eloped (left the premises without authorization and/or any necessary supervision to do so) from the facility. The facility considered the resident leaving Against Medical Advice (AMA), although the resident had a legal guardian and was unable to make medical decisions on their own. Facility staff did not have a consistent understanding of the difference between a resident having a leave of absence, elopement, and against medical advice, to ensure policies and procedures were followed accordingly. The facility failed to allow the resident to return to the facility when the guardian brought the resident to the facility two days later. The resident was not provided discharge planning or appeal rights to the discharge. The…

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

Based on observation, interview and record review, the facility failed to obtain physician orders and monitor a wound identified by staff for one resident (Resident #27). The census was 145. Review of the Wound Management Policy, revised 10/24/22, showed: -Purpose: provide a system for the treatment and management of residents with wounds including pressure and non-pressure ulcers; -Definitions: Diabetic Neuropathic Ulcer: requires that the resident be diagnosed with diabetes mellitus and have peripheral neuropathy. The diabetic ulcer characteristically occurs on the foot; -Procedure: Assessment: -A licensed nurse will perform a skin assessment upon admission, readmission, weekly, and as needed for each resident; -Upon identification of a wound the licensed nurse will: -Measure the wound (length, width and depth); -Initiate a wound monitoring record sheet: -A wound monitoring record will be completed for each wound; -If the wound monitoring record is not used, documentation will be recorded within the medical record which may include nursing notes, treatment records or care plans;…

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 for Elopement and Wandering for one resident (Resident #1) when the resident eloped (left the premises without authorization and/or any necessary supervision to do so) from the facility. The facility considered the resident leaving Against Medical Advice (AMA), although the resident had a legal guardian and was unable to make medical decisions on their own. Facility staff did not have a consistent understanding of the difference between a resident having a leave of absence, elopement, and against medical advice, to ensure policies and procedures were followed accordingly. The resident sample was 13. The census was 144. Review of the facility's Discharge Against Medical Advice policy, last revised 10/24/22, showed: -A resident may discharge themselves from the facility against the advice of his/her physician; -The facility and/or physician will discuss with the resident and/or the resident's representative, if applicable, the reason…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the respiratory services provided were consistent with professional standards of practice for one resident (Resident #3) when staff failed to ensure the oxygen was in working order when it was administered to the resident who had shortness of breath. The facility called Emergency Medical Services (EMS), who found the resident hypoxic (low level of oxygen) and the oxygen was not turned on. In addition, the facility failed to ensure staff followed physician's orders for the rate of oxygen and failed to properly change and date oxygen tubing (Resident #2). The facility identified three residents with orders for oxygen. The sample size was 13. The census 144. Review of the facility's oxygen administration policy, revised 10/24/22, showed: -Initiation of Oxygen: A physician's order is required to initiate oxygen therapy, except in an emergency situation. The order shall include: -Oxygen flow rate; -Method of administration (e.g. nasal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the handrails on each resident hall were properly maintained. This deficient practice had the potential to affect all residents on these halls. The facility census was 145. 1. Observation of 100 South unit on 11/4/24 at 10:25 P.M., showed: -Loose handrail outside of room [ROOM NUMBER]. The handrail was detached from the wall on one side; -Missing handrail between rooms [ROOM NUMBERS]; -Loose handrail outside of room [ROOM NUMBER] and 104. The handrail was missing screws; -Loose handrail outside room [ROOM NUMBER]; -Loose handrail outside of room [ROOM NUMBER]; -Loose handrail outside of the soiled utility room and nurse's station; -Loose handrail outside of the shower room; -Loose handrails on both left and right side outside the TV room. 2. Observation of 100 Main unit on 11/4/24 at 10:37 A.M., showed: -Loose handrail outside of room [ROOM NUMBER]. Plaster on the wall also detached; -Loose handrail outside of shower room in front…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment for two of three dining rooms in use by residents and several common areas. The 300 main dining room had leaks, broken chairs, trash bags stored on the floor, and soiled curtains. The 200 main dining room had a leak. The 200 main day room with water leaks on the carpet. The 200 hall had cracks in the floor. In addition, the 100 hall had a Personal Protective Equipment (PPE) container in use that was soiled. The facility census was 145. 1. Observation of 300 Main dining room, showed: -On 11/4/24 at 10:53 A.M., large brown stains covered the lower half of the curtains that hung up in the windows. There was a wet spot located on the floor and a yellow substance underneath the curtains; -On 11/4/24 at 11:30 A.M., six chairs with torn or detached seats. One resident sat on the edge of a chair that had a large tear visible in the center of the seat. During an attempted interview 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 ensure all residents were treated in a manner to maintain dignity and respect for one sampled resident (Resident #5) after staff failed to close the door and pull the privacy curtain before providing incontinence care. The sample size was eight. The census was 145. Review of the resident bill of rights, showed: -Right to privacy: Residents have the right to privacy in their treatment and care, and to have their personal affairs kept confidential; -Right to dignity: Residents have the right to be treated with dignity and respect at all times. Review of Resident #5's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/9/24, showed: -Cognitively intact; -Diagnoses included deep venous thrombosis (blood clots), neurogenic bladder (urinary problems due to disease or injury to the central nervous system), septicemia (blood poisoning), seizure disorder, and anxiety; -Required substantial/maximum assistance with showers/bathe self and personal hygiene.…

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 151. Review of the facility's Nursing Department, Staffing, Scheduling, and Postings policy, revised 10/24/22, showed the facility must use the services of an RN for at least eight consecutive hours a day, seven days a week, unless a waiver applies. Review of the facility's staffing sheets, dated 6/1 through 7/9/24 showed no RN coverage for the following dates: -6/1, 6/2, 6/15, 6/16, 6/17, 6/18, 6/19, 6/20, 6/21, 6/22, 6/23, 6/29, 6/30, 7/6, and 7/7/24; During an interview on 7/10/24 at approximately 12:00 P.M., the Staffing Coordinator said the facility currently has one as needed (PRN) RN but can utilize agency staff to cover the RN vacancy on the schedule. During an interview on 7/16/24 at 11:16 A.M., the Administrator said she expected the Staffing Coordinator to schedule RN coverage eight hours a day, seven days a week. The facility is actively recruiting for RNs online and have sign on 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 designate a person to serve as the Director of Food and Nutrition Services with the appropriate certification. This had the potential to affect all residents who consumed food prepared by the facility. The census was 151. Review of the facility's Dietary Manager job posting, undated, showed: -Job Requirements: you are certified by the Association of Nutrition and Food Service Professionals, you completed a dietary manager exam. During an interview on 7/16/24 at 9:18 A.M., the Dietary Manager said he does not currently have any certifications. He went through the course but never took the test. During an interview on 7/16/24 at 9:27 A.M., the Administrator said the Registered Dietician comes to the facility once a week and is not employed full-time with the facility. She said the Dietary Manager was hired on 9/29/22 and does not have the appropriate certification at this time. She expected the Dietary Manager to have the required certifications.

Based on interview and record review, the facility failed to have a complete and thorough facility-wide assessment to determine what resources are necessary to care for the residents competently during both day-to-day operations and emergencies. The facility assessment did not include staffing ratios required per shift to meet the needs of residents, the need for a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, or the facility's use of locked units for residents identified with cognitive impairments and behaviors. The census was 151. Review of the facility's Facility Assessment, updated 12/13/23, showed: -Persons involved in completing assessment: Administrator, Director of Nursing (DON), Medical Director, Governing Body Representative (representative from facility's corporation); -Resident acuity, per major resource utilization guidelines (RUGs), number/average or range of residents: -Rehabilitation plus extensive services: 72; -Rehabilitation: 71; -Extensive services: 1; -Special care, high: 21; -Special care, low: 6; -Clinically complex: 4;…

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 an Antibiotic Stewardship Program (ASP) that included antibiotic use protocols and a system to monitor antibiotic use. The census was 151. Review of the facility's ASP, revised 10/24/22, showed: -Purpose: To limit antibiotic resistance in the post-acute care setting, improve treatment efficacy and resident safety, and reduce treatment-related costs; -Policy: ASP is designed to promote appropriate use of antibiotics while optimizing the treatment of infections, and simultaneously reducing the possible adverse events associated with antibiotic use; -Procedure: -The Infection Preventionist (IP), a medical professional that develops ways to detect, prevent and control the spread of infections in residents at the facility, and Medical Director will set standards for the use of antibiotics after reviewing antibiotic trends from the previous quarter and outcome reports; -These standards will be updated as indicated, but no less than annually; -The IP, or other similarly qualified healthcare professionals, will educate…

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 and maintain a tracking system for Certified Nursing Assistant (CNA) 12 hour training requirements for five out of five sampled CNAs. The census was 151. A policy related to CNA 12-hour training was not provided by the facility. Review of the five sampled CNAs' (CMT HHH, CMT OO, CNA E, CNA T, and CNA M) employee training records showed: -Multiple dated in-services and education sheets signed by the CNAs. The signed in-service and education sheets did not list the amount of time each in-service had taken. -No further documentation of tracking the in-services for each CNA provided by the facility. During an interview on 7/10/24 at 4:10 P.M., CNA T said the facility was always in- servicing and providing education, but didn't think the facility was officially tracking the mandatory 12 hours. During an interview on 7/16/24 at 11:16 A.M., the Administrator said the facility was always providing education and in-services to the CNAs, but she had failed to organize and track the yearly mandatory 12 hour trainings 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 observation, interview and record review, the facility failed to provide reasonable accommodation of needs and preferences by failing to ensure three residents had wheelchairs that were in good condition and properly fit the residents (Resident #1, #87, and #127). The facility also failed to provide side rails to assist one resident with bed mobility, positioning, and transfers (Resident #42) and ensure one resident had his/her call light in reach (Resident #89). In addition the facility failed to provide access to community rooms on the third floor, therefore limiting access for the residents to the TV and vending machines for three residents (Resident #46, #138 and #45). The sample was 30. The census was 151. Review of the facility's admission Packet, revised 7/2022, showed the facility shall offer personal care, room, board, dietary services and laundry services. The facility will also offer nursing care, activities, restorative and rehabilitative services, and psychosocial care as identified in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the first floor dining room was free from leaks (Resident #45), failed to ensure furniture and second floor common areas were clean and in good repair (Residents #86 and #106), failed to provide a homelike environment by serving meals with plastic utensils to residents on the second floor (Residents #106, #15, #50, and #126), failed to ensure the third floor shower room was clean and the toilet was in working order (Residents #87), failed to ensure Resident #120's bedroom wall was free from damage, failed to ensure the Air Conditioning (AC) units were free from dust and debris (Rooms 301, 303, 305, and 307), failed to ensure Resident #45 had a closet door. The sample was 30. The census was 151. Review of the facility's Maintenance Services policy, revised 10/24/22, showed: -Purpose: To protect the health and safety of residents, visitors, and facility staff; -Policy: The maintenance department maintains all areas of the building,…

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 perform criminal background checks (CBC) on newly hired employees prior to the employee's start date, in accordance with the facility's policy, for three of 10 employees hired since the last survey. The census was 151. Review of the facility's Staff Screening policy, revised 10/24/22, showed: -Purpose: To ensure the highest quality of care through the utilization of qualified staff, consultants and volunteers; -Policy: The Facility will utilize reasonable and prudent criminal background screening and reference checks for prospective staff, contractors/consultants, registry/temporary staff, and volunteers; -Procedure: Prior to employment or commencement of a contract, the facility will verify and document or obtain a copy, if applicable, of the following information that may include, but not limited to criminal background checks. 1. Review of Certified Nurse Aide (CNA) AAA's employee file, provided for review on 7/10/24, showed: -Hire date 11/1/23; -No CBC requested or received; -Family Care Safety Registry (FCSR) check run…

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 five residents who required assistance with activities of daily living (ADL) received personal care, nail care, and facial hair hygiene in accordance with their needs and preferences (Residents #37, #22, #88, #51, and #124). The sample was 30. The census was 151. Review of the facility's Care and Services policy, dated 10/24/22, showed: -Policy: Residents are provided with the necessary care and services to maintain the highest practicable physical, mental, and social well-being level in an environment that enhances quality of life in the scope of a long-term care facility. Care and services are provided in a manner that consistently enhances self-esteem and self-worth; -Procedure: The Facility will have sufficient staff to provides services to residents with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental…

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 fully implement the restorative therapy program for residents with limited mobility. The facility failed to ensure appropriate services and assistance to maintain or improve mobility for three residents (Residents #88, #4 and #123 ). Resident #88's therapy was discontinued due to insurance and restorative services was not recommended. Resident #88 also had a hand contracture, with therapy recommendations for a hand splint that was not ordered. The sample was 30. The census was 151. Review of the facility's Restorative Nursing Program policy, dated 10/24/22, showed: -Purpose: The Restorative Nursing Program provides nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. This program actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning; -Policy: A resident may be started on a Restorative Nursing Program: Upon admission 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 interview and record review, the facility failed to ensure sufficient number of staff to meet the residents' needs. In addition, the facility failed to provide wound treatments for two residents (Resident #89 and #2) due to lack of nursing staff. The sample size was 30. The census was 151. Review of the facility's Staffing, Scheduling and Posting policy, revised 10/24/22, showed: -Purpose: To ensure an adequate number of nursing personnel are available to meet resident needs; -Procedure: -The facility will employ sufficient Nursing Staff on an 24 hour basis that meet the appropriate competencies, skill set, and required qualifications to provide nursing and related services to attain or maintain the highest practicable physical, mental and psychosocial well-being for each resident; -In staffing an adequate number of nursing service personnel, scheduling will be done as needed to meet resident needs and will account for the number, acuity and diagnoses the facilities resident populations; -Nursing stations will be staffed with nursing personnel when residents are housed 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 provide residents food at a safe and appetizing temperature for three residents (Residents #30, #58, and #111). The sample was 30. The census was 151. Review of the facility's food temperatures policy, revised 10/24/22, showed: -Purpose: To provide the dietary department with guidelines for food preparation and service temperatures; -Policy: Foods prepared and served in the facility will be served at proper temperatures to ensure food safety; -Acceptable serving temperatures: Eggs should be greater than 135 degrees Fahrenheit (F), meat entrees should be greater than 135 degrees F, cereal or oatmeal should be 135 degrees F. 1. Review of Resident #30's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/12/24, showed: -Cognitively Intact. During an interview on 7/8/24 at 9:14 A.M., the resident said his/her food was cold most of the time when it was delivered to his/her room. 2.…

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

Based on observation, interview, and record review, the facility failed to keep the kitchen equipment clean and floors free of dust, grease, and grime. In addition, staff failed to wear a beard net when preparing food. The census was 151. Review of the facility's weekly cleaning list, dated 1/21/24, showed: -Weekly cleaning: prep table, floors swept and mopped, cook station floors behind the fryers, walk in freezer, and fans and duct work. 1. Observation 7/8/24 of the kitchen, showed: -At 8:31 A.M., the walk-in freezer with trash and food debris on the floor in multiple areas; -At 8:34 A.M., the flour and sugar bulk bins observed to have lids caked with a white powder substance; -At 8:35 A.M., the deep fryer observed with a sticky, dried grease build-up on the sides; -At 8:35 A.M., the floor under the tilt skillet observed with a dark liquid with other debris spilled and puddled; -At 8:36 A.M., a fan in the dish washing room with a dust build-up, blowing on the clean dishes. 2. Observation 7/9/24 of the kitchen, showed: -At 10:47 A.M., a fan in the dish washing room with dust…

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 resident was assessed and demonstrated the ability to safely self-administer medications when the resident self-administered medications via a gastric tube (g-tube, tube surgically inserted into the stomach to administer food, fluid, and nutrition) and did not follow acceptable standards of practice. Staff present at the time failed to provide education on safe medication administration as the medications were being administered (Resident #45). The census was 151. Review of the facility's Medication-Self Administration policy, dated 10/24/22, showed: -Policy: Residents who request to perform medication self-administration will be assessed for capability. The assessment of medication self-administration will ensure a clinically appropriate, effective process for the resident to provide self-care. The facility is responsible to ensure medications are administered as ordered by the attending physician even when self-administered; -Procedure: During the admission process, residents will be asked if they…

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 update records of residents' personal possessions per facility policy for two sampled residents (Resident #42 and #39). Resident #42 purchased dresses and socks that were not documented on the resident's inventory sheet and were missing after being sent to laundry. Resident #39 purchased shirts and pants that were not documented on the resident's inventory sheet and were missing after being sent to laundry. The sample was 30. The census was 151. Review of the facility's admission policy, revised July 2022, showed: -Laundry services: The facility will clean the resident's laundry (in commercial machines with industrial detergent) at no additional charge to the Resident. The family will pick up and clean the resident's laundry and the family will provide a covered, plastic laundry container to the facility; -Family will ensure that the resident's clothing has been pre-marked with his or her name and is periodically remarked as needed. 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.

Based on observation, interview and record review, the facility failed to address behaviors related to pulling the call light out of the wall, on the care plan for one sampled resident (Resident #96). The sample was 30. The census was 151. Review of Resident #96's medical record, showed his/her diagnoses included Alzheimer's disease, muscle weakness, insomnia, depression, low blood pressure, high cholesterol, anxiety disorder and difficulty in walking. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/30/24, showed: -Severe cognitive impairment; -Required supervision or touching assistance from staff with eating, oral hygiene, upper body dressing, putting on or taking off footwear and personal hygiene; -Required partial to moderate assistance from staff with toileting, showering, lower body dressing; -Independent for locomotion. Review of the resident's care plan, in use at the time of survey, showed: -Focus: The resident has an Activities of Daily Living (ADLs) deficit; -Goal: The resident 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 interview and record review, the facility failed to document a resident's involvement in discharge planning for one resident (Resident #299), who was transferred to another facility. The census was 151. Review of the facility's Transfer and Discharge Planning policy showed: -Purpose: To ensure that adequate preparation and assistance is provided to residents prior to transfer or discharge from the facility; -Policy: Social Services staff will conduct a Discharge Planning Assessment and will help orient the resident to the impending discharge. -Procedure: -Social Services staff will document the discharge planning, preparation, and the resident's post-discharge needs in a Discharge Planning Assessment, or similar form in the electronic health record; -The Discharge Planning Assessment will be filed in the resident's medical record. Review of Resident #299's medical record, showed: -admission date 12/8/23; -Resident is his/her own responsible party; -Diagnoses included stroke, atrial fibrillation (irregular heartbeat), acquired absence of left leg below knee, acquired absence…

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 a discharge summary was completed for one resident, including a recapitulation of the resident's stay and a final summary of the resident's status at the time of discharge (Resident #299). The census was 151. Review of the facility's Transfer and Discharge Planning policy showed: -Purpose: To ensure that adequate preparation and assistance is provided to residents prior to transfer or discharge from the facility; -Policy: Social Services staff will participate in assisting the resident with transfers and discharges and preparing the Discharge Summary and Discharge Care Plan as part of the interdisciplinary team (IDT); -Social Services staff will assist in developing the Discharge Summary and Discharge Care Plan that is developed with the IDT; -Members of the IDT may use Discharge Planning Questionnaire, or similar form in the electronic health record, to gather information to complete the Discharge Summary and Discharge Care Plan for the resident. The IDT team should ask the resident, resident's family members,…

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

Based on observation, interview and record review, the facility failed to ensure one resident's room was free from hazardous chemicals at the bedside (Resident #124). The sample was 30. The census was 151. Review of the Material Safety Data Sheet (MSDS) for Odoban (disinfectant cleaner), dated 2/10/2022, showed: -Regulatory information: immediate health hazard; -Hazard statement: may cause respiratory irritation. Causes serious eye irritation. Review of the MSDS for Raid Ant and Roach Killer, dated 9/6/2016, showed: -Precautions for safe handling: avoid contact with skin, eyes and clothing, do not enter places where used or stored until adequately ventilated, flammable. Review of the MSDS for Febreeze Air Effects, dated 2/24/2014, showed: -Advice on safe handling: use personal protective equipment as required. Keep container closed when not in use. Review of Resident #124's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/5/24 showed the following: -Diagnoses of schizoaffective disorder (combination of schizophrenia…

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 one of five sampled residents (Resident #93), diagnosed as having dementia with depression and exhibiting symptoms/behaviors, received the appropriate treatment and services to attain or maintain his/her highest practicable physical, mental and psychosocial well-being. The facility failed to follow the recommendations from his/her psychiatric Nurse Practitioner (NP) and there was no Social Service documentation of the resident's behaviors and individualized interventions provided by Social Services. The census was 151. Review of the facility's policy titled, Physician Orders, revised 10/24/22, showed: -Purpose: This will ensure that all physician orders are complete and accurate; -Other orders will include a description complete enough to ensure clarity of the physician's plan of care; -Documentation pertaining to physician orders will be maintained in the resident's medical record. Review of Resident #93's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff,…

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

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 and facility policy in two of two medication rooms and three of five medication/treatment carts. The census was 151. Review of the facility's Medication Storage Policy, dated 1/2021, showed: -Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications; -Medications requiring refrigeration or temperatures between 36 degrees Fahrenheit and 46 degrees Fahrenheit are kept in a refrigerator with a thermometer to allow temperature monitoring. A temperature log or tracking mechanism is maintained to verify that the temperature has remained in acceptable limits. The temperature of any refrigerator that stores vaccines…

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 residents received mechanically altered diets in accordance with physician orders (Residents #127 and #15). The census was 151. Review of the facility's Therapeutic Diets policy, revised 10/24/22, showed: -Purpose: To ensure that the facility provides therapeutic diets to residents that meet nutritional guidelines and physician orders; -Policy: Therapeutic diets are diets that deviate from the regular diet and require a physician order. Per the physician order, therapeutic diets are planned, prepared and served in consultation with the Dietitian; -Procedure: -The nursing staff is responsible for communicating the physician's order for a therapeutic diet to the dietary department in writing; -The therapeutic diet will be reflected on the resident's tray card. -The Dietary Manager will periodically review the resident's tray card and the physician's dietary orders to ensure that the information is consistent. 1. Review 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 maintain medical records that are complete and accurately documented in accordance with acceptable professional standards and practices and with the facility's policies, when staff revised an assessment completed three months ago for one resident (Resident #45). The sample was 30. The census was 151. Review of the facility's Falsification and Omission policy, revised 10/24/22, showed: -Purpose: To ensure entries in the medical records provide an accurate description of the services provided; -Policy: Entries in a medical record at the facility will be factual and will accurately reflect the services provided to the resident, the condition of the resident, and the resident's response to services provided; -Procedure: -The original entry in a record is not to be destroyed or removed from the record; -Errors in the record may be corrected or amended. See policy Completion and Correction; -A deficiency in any omitted entry or incorrect entry that is not knowingly omitted or documented incorrectly; -Willful…

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 acceptable standards of practice for infection prevention and control, when staff failed to utilize Enhanced Barrier Precautions (EBP), an infection control method that uses personal protective equipment (PPE), gowns and gloves, to reduce the spread of multidrug-resistant organisms (MDRO, a germ resistant to many antibiotics), for one resident (Resident #22). In addition, the facility failed to use proper infection control techniques when obtaining blood glucose and administering insulin to one resident (Resident #133). The sample was 30. The census was 151. Review of the facility's Standard and Enhanced Precautions policy, revised 4/1/24, showed: -Purpose: To ensure the use of appropriate protective equipment to improve infection control as required in the care of the residents; -Policy: The facility will utilize current guidance from the Centers for Disease Control (CDC) and the Centers for Medicare and Medicaid Services (CMS) to determine the appropriate PPE to be utilized during the care 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 ensure beds in three shared rooms were equipped with curtains to assure full visual privacy for each resident (Residents #37, #126, and an unidentified resident). The census was 151. 1. Review of Resident #37's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/10/24, showed: -Severe cognitive impairment; -Diagnoses included Alzheimer's disease. Observation on 7/8/24 at 10:08 A.M., showed no privacy curtain hung around the resident's bed. Observation on 7/9/24 at 8:33 A.M., showed no privacy curtain hung around the resident's bed. The resident stood next to his/her bed while Certified Nurse Aide (CNA) E assisted him/her in getting undressed. The resident's roommate sat in a chair on his/her side of the room, in full line of sight of the resident getting undressed. Observations of the resident's room on 7/11/24 at 8:50 A.M., 7/12/24 at 11:55 A.M., and 7/15/24 at 7:31 A.M.,…

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

Based on interview and record review, the facility failed to notify one of eight sampled residents, in writing, of a facility-initiated immediate discharge in a language understood by the resident (Resident #8). The census was 156. Review of the facility policy titled, Transfer and Discharge, revised 10/24/22, showed the purpose of the policy was to ensure that residents are transferred and discharged from the facility in compliance with state and federal laws and provide complete, safe, and appropriate discharge planning and necessary information to the continuing care provider. The facility may transfer or discharge a resident for reasons which include that the health and/or safety of individuals in the facility would otherwise be endangered by the resident's presence. Facility staff is to provide the resident with reasonable advance notice of the transfer or discharge before it occurred. In cases in which 30 days' notice is not possible, the notice of transfer or discharge should be provided to the resident or resident's representative as soon as is practicable. Documentation 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 one resident (Resident #7) was free from physical abuse. On 9/21/23, Resident #4 hit Resident #7, resulting in small laceration (cut) to left eye brow, bottom lip and left upper and bruising with some swelling under left eye and bridge of nose. The sample was 10. The census was 146. Review of the facility's Abuse Prevention and Prohibition Program policy, dated revised: October 24, 2022, showed: -Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The Facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property; -The Facility is committed to protecting residents from abuse by anyone, Including but not limited to facility staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians,…

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 T2XB12 Based on interview and record review, the facility failed to thoroughly investigate an abuse allegation for one resident (Resident #3), when he/she alleged an African American male Certified Nursing Assistant (CNA), threatened him/her. Appropriate staff and resident interviews were not conducted. The sample was 10. The census was 146. Review of the facility's abuse policy, dated 10/24/22, showed: -Purpose includes: To ensure the facility established, operationalized, and maintained an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the investigation of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements; -The investigator may take some or all of the following steps: -Reviews all relevant documentation; -Interviews any witnesses to the alleged incident; -Interviews the resident (as medically appropriate); -Interviews facility staff members who have had contact with the resident during the period of the alleged…

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 See T2XB11 Based on interview and record review, the facility failed to ensure services provided met professional standards when one resident (Resident #2) with a head laceration, related to a fall, did not receive neurological checks (neuro checks, an assessment completed by nursing staff to monitor for changes in the resident's neurological (nervous system) status); and failed to ensure one resident (Resident #7 ) received neuro checks after another resident hit him/her in the head with their fist. The sample of residents with head injuries or unwitnessed falls was four. The census was 146. Review of the facility Neurological Assessment Policy, dated revised 10/24/22, showed: -Purpose: To provide guidelines for the performance of a neurological assessment on residents; -Policy: Nursing will perform a neurological assessment in the following circumstances: --Upon Attending Physician order; --Following an unwitnessed fall and neither the resident nor anyone else know how he/she got there; --Following a fall 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.

See T2XB11 Based on interview and record review, the facility failed to ensure three Nurse Aides (NA C, NA A and NA B completed a nurse aide training program within four months of their employment with the facility. The census was 146. Review of the facility's Competency Evaluation Policy, revised dated December 2006, showed the following: -Policy Statement: Nurse aides employed for a period greater that four months must successfully pass a state approved competency evaluation; -Policy Interpretation and Implementation: -Persons completing the training program must successfully pass the competency evaluation test within four months (120 days) of their date of employment. Failure to do so will result in the student having to retake the training program. Persons not successfully completing the competency evaluation, within 120 days, will not be permitted to continue their employment until they have successfully passed the competency evaluation; -Persons may take the competency evaluation three times. Failure to pass the test on the third attempt will require the person to 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.

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 roaches, mice and gnats in resident rooms (Residents #19, #16, #10, #5 and #18) and common areas. The census was 160. Review of the facility's Pest Policy, revised 10/24/22, showed: -Purpose: To ensure the facility is free of insects, rodents, and other pests that could compromise the health, safety, and comfort of residents, facility staff, and visitors; -The Administrator arranges for a pest control company (Company) to visit and inspect the facility at least once a year; -The company representative will inspect the facility and grounds for insects, termites, rodents, and any other pests that may cause damage to the facility; -Submit a written report to the Administrator detailing its findings; -Department and area staff are responsible for carrying out these recommendations to prevent pests in their respective areas and keeping documentation in accordance with department and 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.

Based on observation, interview and record review, the facility failed to ensure one resident was free from physical restraint when, Certified Nurse Aide (CNA) D, pinned the resident's wrists to his/her chest to provide care (Resident # 13). The sample was 20. The census was 160. Review of the facility's Restraint policy, revised June 2020, showed: -Residents shall be provided an environment that is restraint-free, unless a restraint is necessary to treat a medical symptom in which case the least restrictive measures shall be used; -Physical Restraint is defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body; -The facility honors the resident's right to be free from any restraints that are imposed for reasons other than treatment of the resident's medical symptoms. The facility will ensure restraints will not be imposed for purposes of discipline or convenience; -Medical symptoms will be evaluated 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 interview and record review, the facility failed to thoroughly investigate an abuse allegation for one resident (Resident #3), when he/she alleged an African American male Certified Nursing Assistant (CNA), threatened him/her. Appropriate staff and resident interviews were not conducted. The sample was 10. The census was 146. Review of the facility's abuse policy, dated 10/24/22, showed: -Purpose includes: To ensure the facility established, operationalized, and maintained an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the investigation of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements; -The investigator may take some or all of the following steps: -Reviews all relevant documentation; -Interviews any witnesses to the alleged incident; -Interviews the resident (as medically appropriate); -Interviews facility staff members who have had contact with the resident during the period of the alleged incident;…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure services provided met professional standards when one resident (Resident #2) with a head laceration, related to a fall, did not receive neurological checks (neuro checks, an assessment completed by nursing staff to monitor for changes in the resident's neurological (nervous system) status); and failed to ensure one resident (Resident #7 ) received neuro checks after another resident hit him/her in the head with their fist. The sample of residents with head injuries or unwitnessed falls was four. The census was 146. Review of the facility Neurological Assessment Policy, dated revised 10/24/22, showed: -Purpose: To provide guidelines for the performance of a neurological assessment on residents; -Policy: Nursing will perform a neurological assessment in the following circumstances: --Upon Attending Physician order; --Following an unwitnessed fall and neither the resident nor anyone else know how he/she got there; --Following a fall or other…

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 acceptable standards of practice when staff failed to follow their policy to obtain one resident's wound care orders timely (Resident #6). The sample was 20. The census was 160. Review of the facility's Wound Care Policy, revised October 2010, showed: -Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing; -Preparation: Verify that there is a physician's order for this procedure; -Documentation: The following information should be recorded in the resident's medical record: the type of wound care given; any change in the resident's condition; all assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound; if the resident refused the treatment and the reason(s) why; -Reporting: Notify the supervisor if the resident refuses the wound care; report other information in accordance with facility policy and professional standards of practice. Review of the facility's Physician Orders Policy, revised 10/24/22, showed:…

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

Based on interview and record review, the facility failed to ensure three Nurse Aides (NA C, NA A and NA B completed a nurse aide training program within four months of their employment with the facility. The census was 146. Review of the facility's Competency Evaluation Policy, revised dated December 2006, showed the following: -Policy Statement: Nurse aides employed for a period greater that four months must successfully pass a state approved competency evaluation; -Policy Interpretation and Implementation: -Persons completing the training program must successfully pass the competency evaluation test within four months (120 days) of their date of employment. Failure to do so will result in the student having to retake the training program. Persons not successfully completing the competency evaluation, within 120 days, will not be permitted to continue their employment until they have successfully passed the competency evaluation; -Persons may take the competency evaluation three times. Failure to pass the test on the third attempt will require the person to be terminated from…

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

Based on interview and record review, the facility failed to ensure general accounting principles were followed by failing to provide explanations for discrepancies noted during monthly resident trust fund reconciliations for two accounts, and by failing to complete monthly account reconciliations for a third account in which resident funds were held. In addition, the facility failed to follow up on outstanding checks, and failed to provide quarterly statements to residents and their representatives. This affected 110 residents whose funds were handled by the facility. The census was 121. Review of the facility's Cash Disbursement Procedure policy, undated, showed no guidance regarding resident trust account reconciliation, outstanding checks, or quarterly statements. 1. Review of the facility's Trust Account Reconciliation from January through December 2021, showed: -January 2021: -Bank balance as of 1/31/21: $157,485.53; -Total of 111 resident accounts as of 1/31/21: $157,723.77; -The facility showed a difference of $0.00; -Discrepancy explanation: blank; -February 2021: -Bank…

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 third party liability (TPL) forms were completed for the final accounting for residents who expired, within 30 days. This affected five residents who expired and had money in their account (Residents #323, #322, #350, #321 and #320). The census was 121. 1. Review of Resident #323's resident fund account, showed the following: -He/she expired on [DATE]; -He/she had a balance of $866.38; -No documentation of TPL completed. 2. Review of Resident #322's resident fund account, showed the following: -He/she expired on [DATE]; -He/she had a balance of $2,441.22; -No documentation of TPL completed. 3. Review of Resident #350's resident fund account, showed the following: -His/her account closed on [DATE]; -He/she had a balance of $90.00; -No documentation of TPL completed. 4. Review of Resident #321's resident fund account, showed the following: -He/she expired on [DATE]; -He/she had a balance of $5,499.72; -No documentation of TPL completed. 5. 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.

Based on interview and record review, the facility failed to ensure they maintained an adequate 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 121. Review of the facility's Cash Disbursement policy, undated, showed no instructions on how to monitor the facility's surety bond to ensure it was sufficient. Review of the resident trust account for the past 12 months, from January 2021 to December 2021, showed an average monthly balance of $187,000. (This would yield a required bond in the amount of $280,500 (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 $270,000, dated 12/17/21. Review of the ending balance for December 2021, showed an amount of $187,982.86. During an interview on 1/25/22 at 3:28 P.M., the business office manager (BOM) and administrator said the facility does not have any additional policies regarding funds. The corporate…

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

Based on observation and interview, the facility failed to provide reasonable accomodations of resident needs and preferences by not serving meals in a timely manner and at the posted times. This deficient practice affected all residents who ate at the facility. The census was 121. During an interview on 1/18/22 at 8:30 A.M., the Dietary Manager said breakfast was served at 8:00 A.M., lunch was served at 12:00 P.M. and dinner was served at 5:00 P.M. There were three cooks and six dietary aides (DA) working in the kitchen. The main dining room was in use and some residents received meals delivered to their room. Observations of the lunch meal service in the main dining room on 1/18/22, showed: -At 12:02 P.M., eight residents sat in the dining room; -At 12:16 P.M., approximately 10 residents sat in the dining room. No drinks or food were served; -At 12:36 P.M., a DA passed hand sanitizer to residents; -At 12:45 P.M., the DA brought juice and coffee to the main dining room and began to serve drinks to the residents; -At 12:46 P.M., the first plate of food was served in the dining room.…

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

Based on interview, the facility failed to ensure the Business Office Manager (BOM) had access to all resident funds, and to ensure resident requests for less than $100.00 ($50.00 for Medicaid residents) are honored within the same day by not assuring residents had access to their trust account on the weekends. This deficient practice affected all the residents who had a resident trust account. The census was 121. During an interview on 1/25/22 at 10:52 A.M., the BOM said she became employed with the facility in November, 2021. Resident funds are held in the resident trust fund account. In October 2021, the facility changed ownership and opened a new resident trust fund account, Account B. The BOM did not have access to the old account, Account A, until late in December 2021. Funds were held in both accounts until Account A was closed last week. Withdrawals for resident funds are made from a separate account, Account C, through a different bank. BOM does not have access to the account, other than to make withdrawals. She does not know where the money in Account C comes from, or how…

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 and interview, the facility failed to provide a safe, clean and comfortable, homelike environment. The facility failed to repair pipes leaking outside of the facility's dining room and to address the sound levels of a heating unit in one resident's room (Resident #111). In addition, the facility failed to serve resident meals with appropriate dishware and utensils. The census was 121. 1. Observations on 1/18/22 at 1:08 P.M., 1/19/22 at 8:38 P.M., 1/20/22 at 12:34 P.M., and 1/21/21 at 7:20 A.M., showed two ceiling tiles missing in the hall leading to the dining room. Pipes leaked from the missing ceiling tiles, with mop buckets placed underneath them. During a group meeting on 1/20/22 at 2:00 P.M., four out of six residents said the plumbing has been an issue in the facility. Two ceiling tiles outside of the dining room are missing because the pipes underneath them leak and staff put buckets underneath them. The pipes outside of the dining room have been leaking for over a year and sometimes…

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 one on one (1:1) activities for six of 23 residents who were identified as receiving 1:1 activities (Residents #45, #89, #82. #101, #115, #20, and #9). In addition, the facility failed to provide 1:1 activities for one resident identified by staff as having the desire to participate in 1:1 activities. The sample was 24. The census was 121. 1. Review of Resident #45's medical record, showed: -admission date of 7/16/18; -Diagnoses included traumatic brain injury, aphasia (impairment of expression and understanding of language), seizures, dementia, and quadriplegia (paralysis affecting all four limbs). Review of the resident's quarterly activity participation review, dated 9/6/21, showed: -Resident is on 1:1 with activity staff. Resident will refuse any activity offered, but will socialize with staff; -Resident likes when staff communicate with him/her and likes to watch television in his/her room, mostly lying in bed. He/she will…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to appropriately store non-expired medications and equipment in two of three facility medication storage rooms and in one of five nurse treatment carts. Staff also failed to secure narcotic medication. The facility census was 121. Review of the facility's Storage of Medications policy, revised April 2007, showed: -Drugs and biologicals shall be stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers; -The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner; -The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed; -Drugs for external use, as well as poisons, shall be clearly marked as such, and shall be stored separately from other medications;…

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

Based on observation and interview, the facility failed to ensure meal service tray temperatures were maintained to at least 120 degrees Fahrenheit (F). Five out of six residents attending the Resident Council meeting complained about the food temperatures. The census was 121. Observation of the lunch meal service on 1/24/22 at 11:53 A.M., showed the prepared food on the warm server in the kitchen. Styrofoam plates sat on top of the server. Three wheeled carts held beverages. Dietary Aide (DA) D began placing food onto the Styrofoam plates. DA E took the plates and placed them onto the wheeled cart, with the beverages, to deliver to the units. The cart did not have any components to keep the meals warm while in transport. Further observation on 1/24/22, showed: -At 1:00 P.M., the cart which held the lunch trays was delivered to the second floor. The food was served in divided Styrofoam plates. A resident's tray was taken from the cart. The meal consisted of a beef patty, rice and vegetables. The beef patty reached a temperature of 115.5 degrees, using a digital thermometer; -At 1:25…

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 complete an inspection of bed frames, mattresses and bed rails as part of a regular maintenance program to identify areas of possible entrapment for four of 24 sampled residents to reduce the risks of accidents (Residents #93, #112, #8, and #45). The facility identified 27 residents who utilized bed rails. Of the 27 residents, four were sampled and problems were identified with all four. The census was 121. Review of the facility's Bed Rail Policy, dated 7/20/20, showed: -Preface: It is the policy of this facility to identify and reduce safety risks and hazards commonly associated with bed rail use. A duo-faceted approach will be used to achieve sustainable quality outcomes, including regular bed maintenances and individual bed rail evaluations. In response to the requirement of providing for a safe, clean, comfortable and homelike environment, the facility's regular maintenance program will include regular inspections of all bed systems…

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 and interview, the facility failed to maintain resident dignity by failing to sit while assisting two (Residents #93 and #115) of 28 sampled residents with meals. The census was 121. Review of the facility's Resident's Right policy, revised 8/2021, showed: -Policy Statement: Employees shall treat all residents with kindness, respect and dignity; -Policy Interpretation and Implementation: -Federal and State laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: -A dignified existence; -Be treated with respect, kindness and dignity. 1. Review of Resident #93's quarterly Minimum Data Set, (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/13/21, showed: -admitted on [DATE]; -Exhibited moderate cognitive impairment; -No behaviors; -Required supervision and set up from staff for eating. Review of the resident's care plan, updated on 12/13/21, in use during the survey, showed: -Focus: The resident…

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

Based on interview and record review, the facility failed to ensure the rights of one resident (Resident #55) out of 24 sampled residents, for unrestricted visitation, when the facility prevented the resident's care and financial power-of-attorney (POA, a person with the legal authority to make decisions regarding another person's medical care and financial matters) from entering the facility, contacting the resident by phone and did not set up visits via a virtual video teleconferencing platform. The census was 121. Review of the facility's policy titled, Resident's Rights, effective 9/2015, showed federal and state laws guaranteed certain basic rights to all residents of the facility. Those rights included the right to visit and be visited by others from outside the facility, access to a telephone, communication with and access to people and services, both inside and outside of the facility and to be supported by the facility in exercising his/her rights. Review of the resident's undated face sheet, showed he/she had a care and financial POA. The face sheet showed special…

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 residents' responsible parties were notified in the event of a significant change for 1 of 24 sampled residents (Resident #55). The census was 121. Review of the facility's Notification of Change policy, revised November 2017, showed the following: -In an emergency situation, the physician is contacted at the same time or will be notified following 911 and once the resident is transferred to the hospital; -In a non-emergent, but acute medical situation (including critical lab values and other diagnostic results) the physician will be paged and if there is no return call in 15 minutes the physician will be notified again. If there is no return call in 5 minutes the Medical Director will be notified; -In a non-emergent, non-acute medical situation, such as normal labs, the physician can be contacted at their convenience; -Any questions about how to notify the physician should be directed to the Director of Nurses (DON), Assistant Director of Nurses (ADON), or nursing supervisor. Review of Resident #55's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide bathing and grooming assistance for two residents dependent on staff for assistance with hygiene maintenance (Residents #82 and #45). The sample was 24. The census was 121. 1. Review of Resident #82's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/10/21, showed: -admission date of 6/16/21; -Moderate cognitive impairment; -No behaviors exhibited; -Required extensive assistance of one person physical assist for bed mobility, dressing, toilet use and personal hygiene; -Total dependence of two (+) person physical assist for transfers; -Upper and lower extremity impairment on one side; -Diagnoses included stroke, coronary artery disease (CAD, heart disease), kidney failure, hemiplegia (paralysis affecting one side of the body), anxiety, depression and psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions). Review of the facility's…

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

Based on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one resident identified with a rash on his/her feet. The facility failed to clarify physician orders for treatment, to administer treatments as needed, and to notify the physician upon a change in condition when the resident developed an abrasion on his/her feet (Resident #45). The sample was 24. The census was 121. Review of the facility's Non-Pressure Skin Evaluation policy, revised 12/2019, showed: -General: To provide guidance on the evaluation of skin tears, bruises, and rashes; -Responsible party: Licensed Nursing Staff, Wound Care Coordinator, Treatment Nurse; -Policy: When a resident is identified as having a skin tear, bruise, rash, or other skin condition, the appropriate documentation is completed including notification of physician and resident representative per facility guideline. Once the documentation is completed, a corresponding care plan is developed, if needed; -Procedure: -Skin tear:…

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 adequately support the nutritional status of 1 of 24 sampled residents by not following RD (Registered Dietician) recommendations and physician orders (Resident #115). The facility census was 121. Review of Resident #115's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, updated 12/20/21, showed: -Moderate cognitive impairment. -Resident dependent on staff for all Activities of Daily Living (ADLs). -Diagnoses included dementia, hemiplegia (the functional use of the upper limbs only), seizure disorder, anxiety, depression, and psychotic disorder. Review of the resient's care plan, updated on 12/20/21 and in use during the survey, showed: -Focus: Resident prefers to eat meals in bed, has risk of aspiration while eating in bed, has history of poor appetite, will drink supplements; -Goals: Resident will get out of bed for meals and be free of aspiration through next review; -Interventions: Diet changed to puree, encourage resident to get out of bed for meals, Ensure (a…

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

Based on interview and record review, the facility failed to ensure one resident of 24 sampled residents (Resident #55), diagnosed as having dementia with behavioral disturbance and exhibiting symptoms/behaviors which contributed to a pattern of falls with injury, received the appropriate treatment and services to attain or maintain his/her highest practicable physical, mental and psychosocial well-being by failing to fully inform his/her psychiatric nurse practitioner (NP) of behaviors which included the following: standing unassisted from his/her wheelchair and bed, wandering throughout the secured unit at night with an unsteady gait, screaming and attempting to enter other residents' rooms. The facility failed to obtain a urine specimen as ordered in a timely manner, failed to ascertain urinalysis results and report them to the NP. Additionally, the facility failed to update the Interdisciplinary team (IDT) of the resident's behaviors, develop and implement a plan of care to address his/her needs. The census was 121. Review of the facility's policy titled, Fall Evaluation 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.