Lansdowne Village

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two residents received an accurate assessment, reflective of the residents' status at the time of assessment, when the Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) was incorrectly coded that the residents received insulin. (Residents #4 and #74). The sample was 24. The census was 121. 1. Review of Resident #4's quarterly MDS, dated [DATE], showed:-Diagnoses included diabetes;-Record the number of days that insulin injections were received during the last 7 days or since admission/entry or reentry if less than 7 days: one. Review of the order summary report, dated 10/1/25, showed a physician order for Ozempic (glucagon-like peptide-1 (GLP-1) receptor agonist) subcutaneous (under the skin) solution pen injector 2 milligram (mg)/1.5 milliliter (mL), inject 2 mg subcutaneous every Saturday related to type 2 diabetes mellitus. 2. Review of Resident #75's quarterly MDS, dated [DATE], showed:-Diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents who required assistance with personal care received the care timely for three residents who were left wet/soiled for extended periods (Residents #10, #59 and #6). Moreover, the facility failed to ensure staff cleansed all areas of the skin for these residents during incontinence care. The sample size was 24. The census was 121.Review of the facility's Incontinent Care policy, dated 7/21/22, showed:-The facility will provide incontinence care as directed in the plan of care;-Perform hand hygiene and apply gloves;-Remove soiled brief/under-pad;-Cleanse perineal area from front to back;-Cleanse the rectal area;-Use a clean surface area of the cloth for each wipe;-Remove gloves and perform handy hygiene and apply clean gloves;-If necessary, apply protective ointment;-Remove gloves and perform hand hygiene;-Reposition resident in a safe/comfortable position. 1. Review of Resident #10's quarterly Minimum Data Set (MDS, a…

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

Based on observation, interview and record review, the facility failed to adequately provide assistance to promote good nutrition. The facility identified 33 residents who received fortified foods. On one of one day of meal preparation observation, the facility failed to prepare and serve fortified food, super cereal. The facility failed to ensure one resident (Resident #11) with nutritional needs received fortified foods, health shakes and one on one meal assistance, as ordered. The sample size was 24. The census was 121.Review of the facility's Weight Variances policy, dated 3/31/21, showed:-Policy: All residents who experience significant, insidious and/or unintentional/unplanned weight loss or gain shall be assessed for nutritional status by the Registered Dietician (RD) to include but not limited to adding calorie rich/preferred snacks between meals, fortification, supplements, liberalizing diet and plan for expected weight changes. 1.Observation on 9/26/25 at 6:41 A.M., showed [NAME] J opened two quick rolled oats tubs. The tubs appeared to be 42 ounces. He/She poured one full…

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 drugs and biologicals were labeled and stored appropriately. The facility identified ten medication/treatment carts and four medication rooms. Six of the ten carts and two of the four medication rooms were checked for medication storage. Issues were found in four medication carts and one medication room. Staff failed to date an opened Lispro insulin pen (fast-acting insulin used to manage blood sugar levels), to label two opened bottles of Nitroglycerin (used to treat and prevent chest pain in people with coronary artery disease) tablets, to store an opened Ensure (nutritional shakes used as meal supplement) carton with ice or refrigerate, and to make sure an opened topical cream had a cap or cover. In addition, the facility failed to label an opened Breo Ellipta inhaler (used to treat asthma) that was placed on the countertop in the medication room. The census was 121.Review of the facility's Storage of Medication policy, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents received care consistent with professional standards. Staff failed to schedule follow up appointments with the urologist (a doctor that specialized in the urinary system) for one resident (Resident #5) who has recurrent urinary tract infections and severe urethra erosion (damage to the urinary opening) from prolong use of an indwelling urinary catheter (flexible tubing that carries urine to outside of body into a urine catch bag). The sample size was 6. The census was 123. Review of the facility's Policy and Procedure for Physician Order, dated 9/28/2022, showed: -To provide guidance and ensure physician orders are transcribed and implemented in accordance with professional standards, state and federal guidelines; -Service provided by licensed nurse, nursing administration and Director of Nursing (DON); -Orders must be recorded in the medical record by the licensed nurse authorized to transcribe such orders. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure their licensed staff was competent in their knowledge of the facility policy for when to provide Cardiopulmonary Resuscitation (CPR, an emergency procedure consisting of chest compressions often combined with artificial ventilation to restore blood circulation and breathing) for one resident whose physician ordered him/her as a full code (CPR desired) when staff failed to have knowledge of when CPR would not be indicated in a full code resident, such as when there is evidence of clinical signs of irreversible death (Resident #3). This had the potential to affect 74 residents at the facility who have a full code status. The sample size was 6. The census was 120. Review of the facility's CPR policy, last reviewed [DATE], showed: -The Facility will provide Basic Life Support, prior to the arrival of Emergency Medical Services (EMS) including initiation of CPR to a Resident who experiences cardiac arrest (cessation of respirations and/or pulse) 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 ensure residents had complete, accurate, and individualized care plans to address the specific needs of the residents for three sampled residents, including one closed record (Residents #110, #51 and #112). The resident sample was 23. The census was 113. 1. Review of the facility's Comprehensive Person-Centered Care Plan Policy, revised 10/23/19, showed: -Policy: Each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care; -Procedure: The Comprehensive Person-Centered Care Plan shall be fully developed within 7 days after completion of the admission Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) Assessment; -The Interdisciplinary Team, along with the Resident and/or Resident Representative, will identify resident problems, needs, strengths, life history, preferences,…

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

Based on observation, interview and record review, the facility failed to ensure the floors in the main kitchen and walk in freezer were clean and free from trash and food debris and failed to ensure the air fryer was clean. The sample was 23. The census was 113. Review of the facility's nutritional services sanitation policy, dated 3/31/21, showed: -Policy: nutritional services shall ensure a clean and sanitary work environment; to promote and protect food safety; and to maintain compliance with federal, state, and local regulations governing food sanitation and safety; -Procedure: personnel shall be responsible for daily, weekly, and monthly cleaning assignments as determined by the Dietary Manager and/or his/her designee. Cleaning assignments shall include equipment, cabinets, storage areas, walls, food service-related carts, and refrigeration units. Frequency of completion shall be in conjunction with food safety regulation and with consideration of manufacturer guidelines. Cleaning of equipment condensers, lights, vents/fans, ceiling, ice machine, etc. shall be completed by 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 three residents who required staff assistance to maintain nail care were provided personal care and hygiene (Residents #112, #72 and #7). The facility also failed to maintain one resident's hair, which was matted and long (Resident #112). The sample was 23. The census was 113. Review of the facility's Nail Care policy, 7/21/22, showed: -Policy: The purpose of Nail Care is to clean the nail bed, trim nails, and prevent infection; -Nails may be cleaned during bathing; -Nursing Assistants do not trim nails on diabetic residents. -Nail Care includes daily cleaning and regular trimming; -Observe/Report changes in the skin color around the nail bed, blueness of the nails, signs of poor circulation, cracking of the skin, swelling, bleeding, etc.; -Stop and report to the Charge Nurse ingrown nails, infection, pain, or nails that are thick and difficult to trim. Review of the facility's Activities of Daily Living (ADLs, bathing, toileting,…

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 a medication error rate of less than 5%. Out of 26 opportunities, three errors occurred resulting in a 11.53% error rate (Residents #18, #15, and #221). The census was 113. 1. Review of the facility's Injectable Medication Administration policy, dated 8/2018, showed: -Purpose: To administer medications via subcutaneous (under the skin, as an injection), intradermal (between the layers of the skin, as an injection) and intramuscular (into the muscle, as an injection) routes in a safe, accurate, and effective manner; -Procedure: -Check order on the medication administration record (MAR) to see that an injection is currently ordered and due; -Remove air bubbles. Prime pen needle per manufactures guidelines. Review of the Novolog (insulin aspart, fast acting insulin) pen (injection device pre-filled with insulin) manufacturer's information, revised 2/2023, showed: -Preparing Novolog pen: -A. Pull off the pen cap. Wipe the rubber stopper…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents remained free of significant medication errors related to the incorrect dosage administration of a controlled medication Ativan (lorazepam, a sedative used to treat anxiety) for one of 23 sampled residents (Resident #99). The census was 113. Review of Resident #99's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/29/23, showed: -admission date 12/22/23; -discharge date [DATE]; -Severe cognitive impairment; -Diagnoses include diabetes, dementia, end stage renal disease (ESRD) and acid reflux. Review of the a Subjective, Objective, Assessment, Plan (SOAP) note by the Nurse Practitioner (NP) Q, dated 1/17/24 at 1:40 P.M., showed: -Subjective: Resident is seen today for concerns of increase in weakness and lethargy. Resident has not been showing much improvement with therapy. Spouse thinks it is his/her medication, memory deficit noted. Spouse trying to appeal stay due 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 that in accordance with accepted professional standards and practices, medical records are maintained that are complete and accurately documented for one resident who obtained injuries and/or change in condition (Resident #33). Staff failed to accurately and completely document a the circumstances of a fight with another resident on 1/7/24, failed to document the circumstances surrounding a fall to include where the resident was found and how they were found on 2/2/24, and follow up observations and assessments regarding a change in condition on 2/7/24. The resident was transported to the hospital on all three dates. The sample was 23. The census was 113. Review of the facility's Accident and Incident documentation and investigation policy, revised 4/26/23, showed: -Policy: Accidents and/or Incidents involving Residents will be investigated and documented on an incident report entry in the electronic health record (EHR). An incident is defined as an occurrence which is not consistent with the routine operation 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 appropriate infection control practices during wound care for one resident (Resident #219) and blood glucose testing for two residents (Residents #18 and #73). The sample was 23. The census was 113. Review of the facility's Wound Management policy, reviewed 11/15/22, showed to promote wound healing of various types of wounds, the facility will provide evidence-based treatments in accordance with current standards of practice and physician orders. Review of the facility's Standard Precautions policy, reviewed 10/25/22, showed: -Policy: The facility will use standard precautions which are the minimum infection prevention practices that apply to all resident care, regardless of suspected or confirmed infection status of the resident, in any setting where health care is delivered. These practices are designed to both protect the employee and prevent from spreading Infections among other residents; -Standard precautions include: Hand…

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 clean and homelike environment and provide housekeeping services necessary to maintain a sanitary interior for two residents (Residents #5 and #21). The census was 128. Review of Resident #5's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 7/6/23, showed: -Severe cognitive impairment; -Extensive assistance required for bed mobility, transfers, dressing, toilet use and personal hygiene; -Total dependence for bathing; -Diagnoses included cancer and dementia. Review of Resident #21's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Extensive assistance required for bed mobility, transfers, dressing, toilet use and personal hygiene; -Physical help in part required for bathing activity; -Diagnoses included anxiety disorder and schizophrenia. Observation on 9/7/23 of Resident #5's and Resident #21's room, showed: -At 7:24 A.M., the room floor felt sticky 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 a resident who is unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene, for one of six sampled residents sampled (Resident #5). The facility failed to provide good grooming and personal care when the resident was observed with dirty and long finger nails and staff did not rinse soap and towel dry as directed during care. The census was 128. Review of Resident #5's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 7/6/23, showed: -Severe cognitive impairment; -Extensive assistance required for bed mobility, transfers, dressing, toilet use and personal hygiene; -Total dependence for bathing; -Diagnoses included cancer and dementia. Observation on 9/7/23 at 7:37 A.M., showed the Certified Wound Care Manager entered the resident's room with supplies to provide wound care. Observation of the resident's hands, showed very long and dirty nails. Underneath the nails was a…

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

Based on observation, interview and record review, the facility failed to follow acceptable standards of practice for infection control when staff provided wound care for a resident and failed to sanitize their hands after removing gloves and prior to touching clean surfaces. In addition, staff positioned the resident's bed so the indwelling urinary catheter bag rested directly on the floor for one resident (Resident #5). The census was 128. Review of the facility's Hand Hygiene policy, dated 4/28/22, showed: -The facility will provide guidelines to employees on proper handwashing and hand hygiene techniques that will aid in the prevention of the transmission of infections; -Hand hygiene should be performed following the clinical indications: Before/after providing care. Contact with blood, body fluids, or contaminated surfaces. Before/After applying/removing Gloves/personal protective equipment. After handling soiled lines/items potentially contaminated with blood, body fluids, or secretions. Review of the facility's Catheter Care policy, dated October 2016, showed: -Purpose: 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 employ a qualified social worker on a full time basis. This had the potential to affect all residents of the facility. The sample was 23. The census was 110. Review of the facility's license and certification records showed the facility was licensed for 145 beds and all 145 beds were certified for Medicaid and Medicare. Review of the Facility Assessment, updated 1/1/22, showed Social Worker Q was identified as staff completing Social Services. Review of the facility's key personnel list, received 3/14/22, showed Social Worker Q was identified in the role of the facility Social Worker. Review of Social Worker Q's employee record, showed a re-hire date of 10/22/20. He/she worked in Admissions. During an interview on 3/21/22 at 4:14 P.M., Social Worker Q said he/she worked in Social Services since 7/6/21. He/she worked in Admissions since he/she was hired by the facility; however, he/she did everything for social services because there was not a steady Social Worker since October 2020. They hired a couple of social workers…

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, facility staff failed to document in writing, their actions and rationale regarding residents' ongoing and/or new concerns expressed during resident group meetings regarding medications being received late or not at all, showers not received, missing property and contact information of local agencies. The facility census was 110. Review of the facility's Resident's [NAME] of Rights, undated, showed: -Residents Rights. The resident has a right to a dignified existence, self determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section; -The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents; -The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their grievance policy and ensure residents were educated on the grievance process. The facility failed to provide prompt resolution of Resident #68's grievance regarding wound care and pain medication administration. The facility also failed to provide prompt resolution of grievances and ensure complaints of lost/stolen items were investigated for three residents (Residents #73, #43 and #7). The facility census was 110. Review of the facility's Grievance/Missing Property policy, dated 8/30/18, revised on 4/28/21, showed: -Residents and resident representatives have the right to voice concerns or grievances, which affect their lives at this facility, without fear of discrimination or reprisal. All residents, resident representatives and families also have the right to report property/items that may be missing; -Purpose: To provide an opportunity for residents, resident representatives, and/or family to present concerns or…

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

Based on interview and record review, the facility failed to ensure the state Nurse Aide (NA) Registry was checked for a Federal Indicator of abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property, for nine out of ten reviewed employees. The census was 110. Review of the Facility's Abuse Prevention Policy, reviewed 4/28/21, showed: -Policy: The facility is committed to protecting the resident from abuse by anyone including, but not necessarily limited to: facility staff, other residents, and staff from other agencies providing services to residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual; -Steps to prevent, detect, and report: The facility conducts employee background checks and will not knowingly employ any individual who has been convicted of abusing, neglecting, or mistreating individuals or misappropriation of property; -The facility will pre-screen all potential new employees and residents for a history of abusive behavior. Review of the facility's Employee Handbook, showed federal…

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 develop a baseline care plan for 12 residents (Resident #313, #312, #314, #217, #215, #216, #214, #266, #367, #364, #368 and #101) of 23 sampled residents within 48 hours of admission to provide instructions needed for the provision of effective and person-centered care of the residents. The census was 110. Review of the facility's Comprehensive Person Centered Care Plan policy, dated 1/23/19, showed: -Definitions: --Interdisciplinary-All disciplines will collaborate to develop a plan of care that meets the residents' needs, preferences, and goals; --Baseline Care Plan-Is developed within 48 hours of admission and updated with a change in resident condition as applicable until completion of the comprehensive care plan; -Procedure: --A Baseline Care Plan is to be developed within 48 hours. Develop initial goals based upon admission orders/resident's input and record on the baseline care plan. Provide the resident or resident's representative a copy 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 residents had complete, accurate, and individualized care plans to address the specific needs of the residents for ten of 23 sampled residents (Residents #43, #96, #42, #10, #364, #368, #101, #213, #104, and #90). The census was 110. Review of the facility's Comprehensive Person Centered Care Plan Policy, dated 1/23/19 and reviewed on 1/24/19, showed: -Each resident will have a person centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team (IDT) will provide care. -Responsibility: Interdisciplinary Team Members; -Definitions: -Interdisciplinary-All disciplines will collaborate to develop a plan of care that meets the residents' needs, preferences, and goals; -Comprehensive Person Centered Care Plan (CCP)-Contains services provided, preference, ability, and goals for admission, desired outcomes, and care level guidelines; -Procedure: -The Comprehensive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure care and services were provided according to accepted standards of clinical practice by failing to document treatments for one resident admitted with a burn (Resident #65). The facility failed to administer medications per physician's orders for ten of 23 sampled residents (Residents #32, #25, #65, #22, #68, #79, #86, #92 ,#104, and #500). The facility failed to document blood sugar results for one resident (Resident #22), failed to document the provision of physical/occupational therapies, and to call for bone density results for one resident (Resident #110), failed to document weekly skin assessments for two residents (Residents #43 and #98), failed to document flushing and checking placement of a gastrostomy tube (g-tube, a surgically placed device used to give direct access to the stomach for supplemental feeding) for one resident (Resident #10), failed to document treatments for two residents (Residents #92 and #104).…

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 care and services related to communication, including speech and language service, by failing to provide language assistive devices for three of three sampled residents (Residents #212, #59, and #62) who communicated in a different language. The facility also failed to update the residents' person centered care plans with information regarding how the resident communicated with staff. The census was 110. Review of the facility's Resident Census and Conditions of Residents form, dated 3/14/22, showed the following resident characteristics: -Do not communicate in the dominant language of the facility: 4 residents; -Use non-oral communication devices: 4. 1. Review of Resident #212's admission MDS, dated [DATE], showed: -Diagnoses included diabetes, thyroid disorder, dementia, anxiety, depression, schizophrenia (a serious mental disorder in which people interpret reality abnormally) and post-traumatic stress disorder (PTSD, a 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 ensure the transportation driver transported residents in a safe manner for two residents (Resident #89 and #500). The facility failed to ensure fall incidents were reported, investigated, interventions implemented, and post-fall monitoring completed for two of three residents sampled for falls (Resident #90 and #89). The facility also failed to ensure medications were stored safely and in accordance with facility policy and procedure. The sample was 23. The census was 110. Review of the facility's Fall Management policy, revised 7/14/17, showed: -Fall event: When a fall occurs, assess resident for injury prior to moving resident; -The Licensed Nurse will complete: Risk report in electronic medical record; -24 hour report; -Communicate all resident falls to the attending physician and the resident's family and document on the incident and accident form; -The Interdisciplinary Team Meeting (IDT) will review all resident falls within 24-72…

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 nursing staff with the appropriate competencies and skill sets assisted residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being for each resident. The facility failed to ensure nursing staff are able to demonstrate competency in skills and techniques necessary to care for residents, by failing to provide wound treatments, failed to verify and administer medications per physician's orders, post fall assessments, assess and identify a resident's need for mental health services. In addition, the facility failed to ensure all staff were adequately trained and informed of facility policies and expectations per acceptable nursing standards. The census was 110. Review of the Facility Assessment, updated 1/1/22, showed: -Education/In-services: Communication: Annually and as needed (PRN); -Resident's rights and facility responsibilities, ensure that staff members are educated on the rights of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident by not ensuring initial and quarterly social service assessments were completed for four (Residents #212, #110, #23 and #43) of 23 sampled residents. The facility also failed to ensure policies and procedures were in place for two of two residents reviewed for appropriateness for the secured unit (Residents #59 and #62). The census was 110. Review of the Facility Assessment, updated 1/1/22, showed: -Services provided based on resident need: Mental health and behavior; -Manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/Post Traumatic Stress Disorder (PTSD), 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were labeled and stored per acceptable standards of practice. The facility failed to ensure two of two medication carts contained insulin vials and insulin pens (pre-measured) that were labeled with an open date, stock medications/supplements did not exceed their expiration date, failed to follow their policy regarding labeling with expiration dates, failed to label one injectable multi-use medication vial and one multi use tube of medication with a resident's name, failed to ensure refrigerated medications did not exceed their expiration date, and failed to ensure refrigerator temperatures were monitored and recorded for two of two medication refrigerators. The sample was 23. The census was 110. Review of the medication storage policy, dated 11/2018, showed: -Policy: Medications and biologicals are stored safely, and properly following the manufacturer's recommendations or those of the supplier; -Procedure:…

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

Based on observation, interview, and record review, the facility failed to ensure a process was in place for STAT (immediate) laboratory testing for influenza to be obtained and results received in a timely manner for five residents (Residents #111, #7, #76, #27, and #45). The facility used specimen collection swabs that were not compatible with their current lab, resulting in delayed testing and diagnosis. The sample was 23. The census was 110. Review of the facility's Laboratory Test policy, reviewed 4/28/21, showed: -Policy: Laboratory tests may be completed on residents upon admission or re-admission if not already performed at the discharging facility. Lab tests are completed as ordered by the physician or physician extender such as Nurse Practitioner, Physician Assistant, and Clinical Nurse Specialist. Physician Orders supersede any guidelines listed in this policy; -Responsibility: All licensed nursing personnel monitored by Director of Nursing (DON) or Designee; -Equipment: Lab scheduling; -Lab requisition form; -Computer; -Procedure: Licensed Nurse, or designee, shall…

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

Based on record review and interview, facility staff did not conduct and document a thorough facility-wide assessment to determine what resources are necessary to care for residents during both day-to-day operations and emergencies. The facility failed to identify the needs of residents who do not communicate in the dominant language of the facility. The facility also failed to accurately document the number of residents with behavioral health needs. The facility census was 110. Review of the facility's Resident Census and Conditions of Residents form, dated 3/14/22, showed the following resident characteristics: -Documented signs and symptoms of depression: 41 residents; -Dementia: 26 residents; -Documented psychiatric diagnosis: 25 residents; -Medications: Any psychoactive medication: 74 residents; -Anti-psychotic medications: 30; -Anti-anxiety medications: 13; -Anti-depressant medications: 47; -Hypnotic medications: 3; -Who do not communicate in the dominant language of the facility: 4 residents; -Who use non-oral communication devices: 4. Review of the Facility Assessment,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to vaccinate eligible residents with the Influenza vaccine as indicated by the current Centers for Disease Control (CDC) guidelines, unless the resident had previously received the vaccine, refused, or had a medical contraindication present for five out of five residents reviewed for Influenza vaccination (Residents #27, #86, #98, #104 and #23). In addition, three residents developed flu-like symptoms (Residents #27, #111, and #45) with one residents testing positive for Influenza A (Resident #27). The sample was 23 residents. The census was 110. Review of the facility's Influenza Vaccine policy, dated March 2017, showed: -Policy statement: All residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza; -Policy Interpretation and Implementation: Between October 1st and March 31st each year, the influenza…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility staff failed to close a privacy curtain or door, leaving one resident (Resident #79) in his/her gown, and one resident (Resident #86) in his/her gown with no brief, and exposed to those in the hall. The facility failed to maintain resident privacy by hanging signs regarding care for specific residents at the nurse's station, visible to all who entered the unit. The facility failed to approach and provide care to one resident (Resident #101) in a respectful and dignified manner when a nurse aide failed provide care in a calm, caring, and patient manner. The census was 110. Review of the facility's Resident [NAME] of Rights, revised November 2016, showed: -Residents Rights: The resident has a right to a dignified existence, self-determination, and communication with/and access to persons and services inside and outside the facility, including those specified in this section; -A facility must treat each resident with respect and dignity and care for each…

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

Based on record review and interview, the facility failed to ensure resident funds were placed in an account separate from the facility operating account. The facility did not provide residents refunds of their personal funds from the operating account in a timely manner for six residents (Resident #12, #14, #34, #35, #37 and #38). The facility census was 110. 1. Record review of the facility's maintained Accounts Receivable Report for the period 03/01/21 through 03/21/22, showed the following residents with personal funds held in the facility operating account. Resident Amount Held in Operating Account #12 $2,039.00 #14 $2,170.36 #34 $ 948.00 #35 $4,511.47 #37 $3,090.00 #38 $2,476.50 Total $15,235.33 During an interview on 03/21/22 at 12:09 P.M., the Business Office Manager said the refunds should have been completed but had not been done.

Based on record review and interview, the facility failed to reconcile the resident trust account monthly, in accordance with generally accepted accounting principles. The facility census was 110. 1. Record review of the facility maintained Resident Trust Account for the period 03/01/21 through 03/21/22, showed the facility could not provide zero-balanced reconciliations for April 2021 through October 2021. During an interview on 03/21/22 at 5:40 P.M., the Regional Business Office Manager said the resident trust reconciliations should show a zero balance for a reconciliation. During an interview on 03/30/22 at 3:50 P.M., the Business Office Manager said they are researching why the account was not reconciling to a zero-balance.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide a final accounting of resident trust fund balances within thirty days to the individual or probate jurisdiction administering the resident's estate from four residents (Resident #10, #22, #24, and #26) out of a sample of six. The facility census was 110. 1. Record review of the facility Discharge List for the period [DATE] through [DATE], showed Resident #10 expired on [DATE]. Record review of the facility maintained Resident Statement for the period [DATE] through [DATE], showed the facility did not submit Resident #10's funds or a Personal Funds Account Balance Report (TPL) for $2,651.29 to the Department of Social Services until [DATE] (143 days after Resident #10 expired.) During an interview on [DATE] at 8:47 A.M., the Business Office Manager said he/she was waiting for insurance to bill before the TPL Form was sent. 2. Record review of the facility Discharge List for the period [DATE] through [DATE], showed Resident #22 expired on [DATE].…

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 imposed a charge for a service for which payment was made under Medicaid for four residents (Resident #5, #8, #19, and #23) out of a sample of 4. The facility census was 110. Record review of the Missouri Department of Social Services, MO Health Net Division State Regulations for Medicaid Reimbursement for Long Term Care Facilities, showed the following: 13 CSR 70-10.010 (5) Covered Supplies, Items and Services. All supplies, items and services covered in the per-diem rate must be provided to the resident as necessary. Supplies and services which would otherwise be covered in a per diem rate but which also are billable to the Title XVIII Medicare program must be billed to that program for facilities participating in the Title XVIII Medicare program. Covered supplies, items and services include, but are not limited to, the following: (K) All routine care items, including disposables and including, but not limited to, those items specified in Appendix A to this rule; Record review of Appendix A showed the following items covered under…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete admission comprehensive assessments within 14 calendar days after admission to the facility and annual comprehensive assessments not less than once every 12 months (366 days) to assess functional capacity using the resident assessment instrument (RAI) for three out of 23 sampled residents (Residents #212, #368 and #364). The census was 110. Review of the facility's MDS 3.0 policy, revised 10/7/21, showed: Policy: The Minimum Data Set (MDS) is a standard comprehensive assessment of all residents in Medicare or Medicaid certified facilities mandated by federal law to be completed and electronically transmitted to CMS (Centers for Medicare and Medicaid Services) in compliance with the guidelines provided in the MDS 3.0 RAI User's Manual; -Responsibility: MDS Coordinator and Interdisciplinary Team (IDT) members; -Procedure: The MDS Coordinator, in conjunction with the IDT, is expected to complete assessments using the MDS 3.0 Resident Assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assess residents using the quarterly review Minimum Data Set assessment timely for two of 23 sampled residents (Residents #7 and #6). The census was 110. Review of the facility's MDS 3.0 policy, revised 10/7/21, showed: Policy: The Minimum Data Set (MDS) is a standard comprehensive assessment of all residents in Medicare or Medicaid certified facilities mandated by federal law to be completed and electronically transmitted to CMS (Centers for Medicare and Medicaid Services) in compliance with the guidelines provided in the MDS 3.0 RAI User's Manual; -Responsibility: MDS Coordinator and Interdisciplinary Team (IDT) members; -Procedure: The MDS Coordinator, in conjunction with the IDT, is expected to complete assessments using the MDS 3.0 Resident Assessment (RAI) specified by the state in compliance with the MDS 3.0 RAI user's manual guidelines; -The MDS Coordinator and/or IDT will use the following when completing the assessment as directed by the RAI…

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

Based on interview and record review, the facility failed to follow appropriate discharge procedures and complete discharge and/or transfer documentation. This affected two out of three closed records reviewed for discharge planning (Residents #218 and #314). The census was 110. Review of the facility's Discharge Plan/Summary- Voluntary policy, last reviewed 10/7/21, showed: -Policy: An interdisciplinary summary is completed on a resident upon discharge to assure the continuum of care needs of the resident are met; -Responsibility: A licensed nurse, social services, therapist, registered dietician/certified food service director, activities director; -Guidelines: -A physician order must be obtained; -Upon notification of impending discharge, the interdisciplinary team (IDT) should be notified to allow staff the opportunity to educate and implement a safe discharge. Social work should coordinate discharge planning process; -When discharged to a healthcare facility, staff should document who the information was sent to and when it was sent, as well as provide the following items:…

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 showers were received as scheduled/desired and to ensure residents were well groomed, clean, and free of odors for four (Residents #368, #313, #32, and #25) of 23 sampled residents. The census was 110. 1. Review of Resident #368's medical record showed: -An admission date of 2/22/22; -Diagnoses included diabetes, left leg above-the-knee amputation, muscle wasting and atrophy. Review of the resident's initial care plan, dated 3/15/22, showed: -Focus: At risk for skin breakdown; -Goal: Will have intact skin, free of redness, blisters, discoloration through review date; -Interventions: Pressure reducing mattress to bed, report changes in skin integrity to nurse. Review of the resident's Activities of Daily Living task sheet (ADLs- daily self-care activities) for the month of March 2022 showed no showers or baths documented. The facility failed to provide bath/skin assessment sheets for the resident. Observation and interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed maintain a system to obtain resident preferences related to initiation of Cardiopulmonary Resuscitation (CPR-basic life support provided prior to the arrival of emergency medical services for residents who experience cardiac arrest-cessation of respiration and/or pulse) upon admission for three residents (Residents #25, #23 and #212). The facility failed to ensure facility staff had access to current code status documentation, to follow up on changes to code status and documentation when requested by the resident (Resident #68, 98, and #73) so that staff knew immediately what action to take or not take if an emergency arises. Additionally, the facility failed to ensure the transportation driver maintained active cardiopulmonary (CPR) certification. The sample size was 23. The census was 110. Review of the facility's Advance Directive policy, dated [DATE], showed: -Policy: It is the policy of the facility to respect the resident's right of self-directed…

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 establish a restorative program for assistance to maintain or improve mobility with the maximum practicable independence. The facility failed to provide recommended restorative services for two sampled residents (Resident #32 and #110) out of 23 sampled residents. The census was 110. Review of the Resident Screening and Assessment for Establishment of a Restorative Nursing Program, dated 1/1/14, showed: -Purpose: To provide guidance on a process for screening and assessing residents for further evaluation and development of a restorative nursing program and serve as a baseline of function; -Procedure: -Upon identification of a potential functional decline, the referring nurse shall complete the restorative assessment form; -The restorative assessment form will be forwarded to the restorative nurse, or the Director of Nursing (DON) in the absence of a restorative nurse for further evaluation; -The restorative nurse will collaborate with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to monitor weights and ensure nutritional services were provide to each resident, consistent with the resident's comprehensive assessment for two residents (Residents #16 and #400). Facility staff failed to ensure weights were obtained and documented as ordered. The sample was 23. The census was 110. Review of the Weight and Hydration Management Overview, dated February 2016, included: -Overview: -The resident's nutritional status will be monitored on a regular basis. Residents are expected to maintain acceptable parameters of nutritional status, such as body weight, protein levels, unless the clinical condition demonstrates this is not possible. The measurement of weight is a guide in determining the nutritional status. Therefore, the evaluation of the significance of weight gain or loss is a crucial part of the assessment process. Nutritional status, including weight, is influenced by calories, protein and fluid; -Nutrients are essential for many…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff provided proper respiratory care when the staff failed to follow physician orders for oxygen therapy (supplemental oxygen) and date oxygen tubing and oxygen humidifiers (device used to humidify supplemental oxygen) for three sampled residents (Residents #23, #79 and #28). The census was 110. Review of the Oxygen Administration and Storage policy and procedure, dated 1/1/14, showed: -Purpose: to ensure staff follow safety guidelines and regulations for storage and use of oxygen; -General guidelines: -Concentrator (medical device that provide extra oxygen) filters: Filters should be removed and cleaned by rinsing with clear, cool water weekly to maximize flow rate of clean air; -Tubing: Oxygen tubing should be of length sufficient to provide the resident with adequate oxygen levels while promoting maximum mobility: -Tubing should be changed weekly; -Nasal cannula (a device for delivering oxygen) tubing may need to be changed…

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 thorough assessments, orders, monitoring and ongoing communication with the dialysis (the clinical purification of blood by dialysis as a substitute for the normal function of the kidney) center for one closed record review (Resident #42). The sample size size 23. The census was 110. Review of Resident #42's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 2/23/22, showed: -Cognitively intact; -No set up/physical assist for dressing, eating, bed mobility, and personal hygiene; -One staff person assistance for transfers and toileting; -Lower extremity impairment, one side; -Walker/Wheelchair for mobility; -Diagnoses included kidney failure, diabetes, and depression. Review of the resident's current electronic physician's order sheet, showed: -An order, dated 1/15/22, up on dialysis days by 6:00 A.M. to be ready for dialysis; -No order to assess the dialysis fistula (a connection made between veins and arteries) by bruit (a sound heard over an artery or vascular channel, reflecting…

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 received appropriate person-centered care and met the highest practicable psychosocial well-being when the facility failed to provide assessment and mental health services for two sampled residents. The facility failed to provide a mental health assessment and social history assessment for one resident who did not speak English, who was admitted with active physician's order for Prazosin, a medication used to treat Post-Traumatic Stress Order (PTSD, a mental health condition that is triggered by a terrifying, shocking, or scary event either by experiencing or witnessing it.) The facility failed to obtain information regarding the resident's history of PTSD, including the stressors and triggers of the trauma, symptoms related to PTSD, and a history and assessment of the resident's diagnoses of schizophrenia (mental disorder characterized by significant alterations in perception, thoughts, mood, and behavior), psychosis,…

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

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 25 opportunities observed, 2 errors occurred resulting in an 8.0% error rate (Residents #7 and #101). The census was 110. Review of the facility's Physician Orders policy and procedure, revised 7/1/17, showed: -Purpose: To provide guidance to ensure physicians' orders are transcribed and implemented in accordance with professional standards; -Policy: -All orders shall be provided by licensed practitioners (physician, nurse practitioner (NP), or physician assistant (PA)) authorized to prescribe such orders; -Orders must be recorded in the medical record by the licensed nurse authorized to transcribe such orders; -Physician orders must be documented clearly in the medical record. The required components of a complete order: date and time of receipt of the order, name of the practitioner providing the order, name and strength of the product, quantity or specific duration, dosage and frequency of administration, route of administration, indication 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 timely provide or obtain the required services from an outside resource, for one resident with physician orders for rehabilitation services (Resident #25). The resident was admitted to the facility with orders for physical and occupational therapy evaluations, which were not completed timely. The sample was 23. The census was 110. Review of the Physician Orders policy and procedure, revised 7/1/17, showed: -Purpose: To provide guidance to ensure physician orders are transcribed and implemented in accordance with professional standards; -Policy: -All orders shall be provided by licensed practitioners (physician, nurse practitioner (NP), or physician assistant (PA) authorized to prescribe such orders. Review of Resident #25's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/18/21, showed: -Severe cognitive impairment; -Total staff assistance with dressing and transfers; -Required extensive staff assistance for toileting and hygiene; -Diagnoses of aphasia…

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 designate a member of the facility's interdisciplinary team who was responsible for working with hospice representatives to coordinate care. The facility also failed to asses a hospice resident's pain level per the physician's order (Resident #264). The census was 110. 1. Review of Resident #264's medical record showed: -An admission date of 1/14/22; -Discharge/death in facility on 1/17/22. Review of the resident's hospital discharge instructions, dated [DATE], showed he/she was admitted for cardiac arrest. Multiple goals of care discussions were had with family and the decision to artificially prolong life was not something the resident would want. He/she was transitioned to comfort care measures. He/she was discharged to a facility on hospice. Hospice care focuses on making you comfortable during the last months of your life. Review of the resident's electronic physician's orders sheet (ePOS) showed: -An order, dated 1/14/22, for acetaminophen…

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