Life Care Center Of St Louis

Based on interview and record review, the facility failed to ensure eight of 10 randomly selected Certified Nurse Aides (CNAs) received the required annual 12 hour resident care training. The census was 92. Review of the facility assessment, showed: -Staff training/Education and Competencies: Facility provides staff training/education and competencies through a variety of methods such as new employee orientation, impromptu small group training during the regular course of business, scheduled in-house in-services, webinars, classes, seminars, memos, Healthcare Academy, etc. on subjects that are either required for continued certification or in areas determined to need education or re-education. The facility provides or arranges for personnel to receive outside education to meet staff certification and re-certification requirements as applicable. The facility provides or arranges for training in the following subject areas. This is not an inclusive list: -Communication; -Resident's right and facility responsibilities; -Abuse, neglect, and exploitation; -Infection control; -Medication…

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 post the required nurse staffing in a prominent place, readily accessible to residents and visitors on a daily basis. The census was 92. Review of the facility assessment, showed: -Scheduling plan: 8 + full-time per unit on 6:30 A.M. to 2:30 P.M. shift; -8 + full-time per unit on 2:30 P.M. to 10:30 P.M. shift; -6 + full-time per unit on 10:30 P.M. to 6:30 A.M. shift. Observations from 4/17/24 through 4/19/24 and 4/22/23 and 4/23/24, showed a board on the wall behind the front desk reception desk. The board contained categories for date, census, total number and actual hours worked by Registered Nurses (RN), Licensed Practical Nurses (LPN), and Certified Nurse Aides (CNA) per shift; -On 4/17/24 at 10:10 A.M., 4/18/24 at 6:20 A.M., and 4/19/24 at 6:44 A.M., showed a date of 4/4/24 and census of 92. There was no documentation of the total number and actual hours worked by RNs, LPNs, and CNAs per shift; -On 4/22/24 at 12:35 P.M. and 4/23/24 at 8:59 A.M., showed a census of 92. The date showed only the month 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 follow acceptable standards of practice for infection prevention and control when staff failed to change gloves while administering medication via an enteral nutrition device (feeding tube) and left suction equipment at the bedside uncovered for one resident (Resident #1), and not testing new hire employees for Tuberculosis (TB) per their policy for eight of eight employees sampled. The census was 92. 1. Review of the facility's Administration of Medications policy, dated 8/24/23, showed: -The facility will ensure medications are administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms. Review of the facility's Enteral Nutrition Therapy policy, dated 8/8/23, showed: -The facility will provide bolus enteral nutrition therapy in accordance with physician orders and professional standards of practice. This facility will utilize the Lippincott procedures, Enteral tube feeding, gastric; -Lippincott Nursing Procedures, Ninth Edition, 2023, page 295 Enteral tube…

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 a comprehensive resident assessment for one of 12 residents investigated for comprehensive assessment completion (Resident #30). The census was 92. Review of the Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) version 3.0 Resident Assessment Instrument (RAI) User's Manual, showed: -For all non-admission assessments, the MDS completion date must be no later than 14 days after the Assessment Reference Date (ARD); -For the admission assessment, the MDS Completion Date must be no later than 13 days after the entry date; -Encoding Data: Within 7 days after completing a resident's MDS assessment or tracking record, the provider must encode the MDS data (i.e., enter the information into the facility MDS software). Review of Resident #30's medical record, showed: -admitted [DATE]; -An annual MDS assessment, dated 4/1/24 with ARD date 2/24/24, in progress. During an interview on 4/22/24 at 10:09 A.M., 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 residents had complete, accurate and individualized care plans to address specific needs of the residents for two of 19 sampled residents (Residents #175 and #59) and one of three sampled closed records (Resident #174). The census was 92. 1. Review of Resident #175's medical record showed: -admitted on [DATE]; -Diagnoses included encounter for surgical aftercare following surgery on the skin and subcutaneous tissue (deepest layer of the skin), severe sepsis (complication of an infection) without septic shock (widespread infection causing organ failure and dangerously low blood pressure), iron deficiency anemia (low red blood cells) secondary to blood loss, unspecified open wound left leg, necrotizing fasciitis (serious bacterial infection that destroys tissue under the skin), muscle weakness, and difficulty walking. Review of the resident's electronic Physician's Orders Sheet (ePOS), dated April 2024, showed: -An order dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed ensure a safe resident discharge to the community by failing to ensure referrals to local contact agencies and orders for medical equipment were sent timely for one of two residents reviewed with an order to discharge home (Resident #174). The resident was discharged without home health set up or durable medical equipment after a change in the discharge date . This has the potential to affect all residents who discharge from the facility. The census was 92. Review of the facility's Discharge Plan policy, reviewed 8/9/23, showed: -Policy: The discharge planning process will address each resident's discharge goals and needs including caregiver support and referrals to local contact agencies, as appropriate, and involves the resident and if applicable, the resident representative and the interdisciplinary team in developing the discharge plan; -Procedure: Identify the patient's needs and goals regarding discharge upon or as soon as practicable after…

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, by failing to provide speech assistive devices for one of one sampled resident (Residents #32) who is deaf. The facility also failed to ensure staff were knowledgeable on how to locate information regarding how the resident communicated with staff. The census was 92. Review of Resident #32's quarterly assessment Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/14/24, showed: -Hearing highly impaired- absence of useful hearing; -Diagnoses included stroke, high blood pressure, and seizures; -No hearing aid or other hearing appliances used. Review of the resident's care plan, dated 5/30/19, showed: -Focus: I have a hearing deficit/deaf and I have difficulty understanding. I prefer to have an American Sign Language (ASL) interpreter to assist me with understanding; -Goal: My needs will be anticipated and met by staff by next review 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for one resident with chronic wounds (Resident #4). The resident readmitted from the hospital on 3/29/24. Hospital records indicated wounds present to the left knee. The facility admission nursing assessment identified open areas on the left knee and lower extremities. The facility did not complete a full wound assessment until 4/3/24. Treatment orders were not obtained for the left plantar (foot) until 4/11/24 and left knee until 4/19/24. The census was 92. Review of the facility's Skin Integrity and Pressure Ulcer/Injury prevention and Management policy, dated 10/3/19 and last revised 8/25/21, showed: -Provide associates and licensed nurses with procedures to manage skin integrity, prevent pressure ulcer/injury (skin injuries as a result of prolonged pressure or friction), complete wound assessment/documentation, and provide treatment…

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 residents receive proper treatment to maintain vision when staff failed to make transportation arrangements for one sampled resident (Resident #224) out of 19 sampled residents, to go to a follow-up appointment for eye surgery and failed to reschedule the appointment after it was missed. The census was 92. Review of the facility's Transportation Coordination and Services Policy, issued 1/27/23 and reviewed on 7/17/23, showed: -Policy: The facility will assist residents in making necessary appointments for services not provided in the facility and arranging for transportation to and from appointments; -Procedure: The facility will assist the resident and or resident representative in the making of necessary appointments, such as, but not limited to Medical Specialists, Laboratory and Vision Services; -The facility will provide transportation through facility transportation or through a contracted service. Review of Resident #224's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument…

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 were free from significant medication errors for one resident who did not receive his/her ordered routine insulin (Resident #29). The census was 92. Review of the facility's Administration of Medications policy, dated 4/24/19 and last revised 2/13/23, showed: -The policy will ensure medications are administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms; -Medication error- this means the observed or identified preparation or administration of medications or biologicals which is not in accordance with: -Physician order; -Manufacturer's specifications regarding the preparation and administration of the medication or biologicals; -Accepted professional standards and principals which apply to professionals providing services; -Significant medication error- this means one which causes the resident discomfort or jeopardizes his or her health and safety. Significance may be subjective or relative depending on the individual situation 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 drugs and biologicals were stored per acceptable standards of practice for one of four medication carts reviewed and one of one treatment cart reviewed. The medication cart contained insulin pens not labeled when removed from refrigeration to indicate when they expire. The treatment cart contained ointments for 2 residents (Residents #74 and #224) with the cap off. The facility had 10 medication/treatment carts. The census was 92. Review of the facility's Storage and Expiration Dating of Medications, Biologicals policy, dated 12/1/07 and last revised 8/7/23, showed: -This policy sets forth the procedures relating to the storage and expiration dates of medications, biologicals, syringes, and needles; -Facility should ensure that medications and biologicals that have an expiration dates on the label, have been retained longer that recommended by manufacturer or supplies guidelines, or have been contaminated or deteriorated, are stored separate from other medication until destroyed or returned to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents received care consistent with professional standards. One resident (Resident #4) did not have his/her treatments completed as per physician orders to his/her vascular wounds, and one resident (Resident #3) did not have a treatment on his/her breasts and no follow up skin assessments were completed to ensure the resident's wound was healing. The sample was five. The census was 87. Review of the facility's Skin Integrity and Pressure Ulcer/Injury Prevention and Management Policy, review date, 3/31/23, showed: -Based on the comprehensive assessment of a resident, the facility must ensure that: -A skin assessment/inspection occurs on admission/readmission. Skin observations also occur throughout points of care provided by Certified Nursing Assistants (CNA) during Activities of Daily living (ADL, bathing, dressing and incontinent care). Any changes or open areas are reported to the nurse; CNAs will also report to the nurse if a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure two residents (Resident #5 and Resident #1) with pressure wounds (skin or soft tissue injury that develops with prolonged periods of pressure over specific areas of the body) received the necessary treatments and services to promote healing. The sample size was five. The census was 87. Review of the facility's Skin Integrity and Pressure Ulcer/Injury Prevention and Management Policy, review date, 3/31/23, showed: -Based on the comprehensive assessment of a resident, the facility must ensure that: -A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; -A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing; -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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to protect residents' rights to be treated with dignity and respect for one resident (Resident #8) who was talked to in a harsh tone and told to go to his/her room and had tissues grabbed out of his/her hand. In addition, staff failed to provide privacy during care for three residents (Residents #38, #25, #23). The census was 52. Review of the Resident Rights, [NAME] of Rights, provided to residents upon admission to the facility, showed: -The resident has a right to a dignified existence, self-determination, and communication with the access to persons and services inside and outside the facility; -The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States; -Residents have the right to be free of interference, coercion, discrimination and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her…

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

Based on interview and record review, the facility failed to ensure residents and/or responsible parties were notified in a timely manner when a resident's account was within the $200 Social Security (SSI) limit ($4,835.00) or when the resident's account was over the SSI limit ($5,035.00). This affected 10 residents reviewed who received Medicaid benefits (Residents #303, #304, #27, #43, #8, #305, #26, #306, #307 and #17). The census was 52. Review of the facility's Management of Resident's Funds policy, undated, included: -Policy: It is the policy of the facility that residents may choose the facility to manage all or part of their financial affairs; -Procedure: The facility will notify each resident that receives Medicaid benefits when the amount in the account reaches $200 less than that which is allowed by the state Medicaid regulations. 1. Review of Resident #303's trust account, showed: -On 2/28/22, he/she had $8,441.33 in his/her account; -No letter showing the facility notified the resident or responsible party that he/she was within $200 of the SSI limit or over the limit.…

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

Based on interview and record review, the facility failed to follow their transfer/discharge policy by not providing the resident and/or their representative the written transfer notice at the time of the resident's facility initiated transfer, for three of five residents investigated for discharge. (Residents #252, #36 and #45). The census was 52. Review of the facility's Transfer/Discharges Policy, dated 5/6/19, showed: -Before a facility transfers or discharges a resident, the facility must-notify the resident and the resident's representative(s) of the transfer or discharge and the reason for the move in writing and in a language and manner they understand 1. Review of Resident #252's medical record, showed: -admission date: 9/29/21; -discharged to the hospital: 10/8/21; -readmission to the facility: 10/14/21. Review of the resident's nurses notes, dated 10/8/21 through 10/14/21, showed on 10/8/21 at 5:45 P.M., the doctor was notified of the residents fall and a new order was received to send the resident to the hospital. At 6:05 P.M., the family was notified. -There was no…

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

Based on interview and record review, the facility failed to inform the resident and/or resident representative of the bed hold requirements at the time of transfer to the hospital for various medical reasons for three of the five residents investigated for bed hold notices. (Resident #252, #36 and #45). The census was 52. Review of the facility's Bed-hold/Room Reservation Policy, dated 5/2/19, showed: -Policy: The Bed-hold policy should be given upon admission, upon transfer of a resident to the hospital (if in an emergency within 24 hours), or if the resident goes on therapeutic leave of absence; -Procedure: Bed hold policies will be provided and explained to the resident or responsible party upon admission and explained to the patient before each temporary absence; -Before the resident transfers to the hospital or the resident goes on a therapeutic leave, the facility will provide written information to the resident or representative or responsible party that specifies: in case of emergency transfer, notice at the time of transfer means that the family, surrogate or responsible…

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 followed physician's orders and/or facility standing orders by failing to notify physicians when resident's blood glucose levels exceeded the parameters. The facility identified 14 residents with orders for routine blood glucose levels. Of those 14, two had blood glucose levels that exceeded physician orders and/or facility standing orders and problems were identified with both. (Residents #26 and #10). Problems were identified with one of one discharged resident with orders for routine blood glucose levels. (Resident #301). In addition, the facility failed to ensure one resident received their tube feeding formula as ordered, failed to identify the correct arm for taking blood pressures for one resident with a dialysis shunt, failed to ensure one resident using oxygen and a continuous positive airway pressure (c-pap) machine had orders for the oxygen and c-pap machine, and failed to discontinue one resident's order 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 an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities, designed to meet the interests and preferences for one resident, Resident #13. The facility failed to ensure there was a current activities scheduled in the evenings and on weekends and failed to ensure scheduled activities occurred. The facility also failed to provide meaningful and appropriate one on one (1:1) activities. The facility identified 16 residents that received 1:1 activities. Of those 16, five were sampled and problems were identified with three residents (Residents #32, #23, and #17). The census was 52. Review of the facility Therapeutic Activities Program policy, reviewed on 5/18/20 and revised on 11/2/21, showed: Federal Regulation: -The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents…

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

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 26 opportunities observed, 3 errors occurred resulting in a 11.53% error rate (Residents #251, #41 and #26). The census was 52. Review of the facility's Administration of Medications policy, revised 7/14/21, showed -All medications are administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms; -Medication error means the observed or identified preparation or administration of medications or biologicals are not in accordance with: -The prescriber's orders; -Manufacturer's specifications regarding the preparation and administration of the medication or biological; -Acceptable professional standards and principles, which apply to professionals providing services; -A physician order that includes dosage, route, frequency, duration and other required considerations including the purpose, diagnosis or indication for use is required for administration of medication. 1. Review of Resident #251's electronic…

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 practices to include storage of insulin, dating medications when opened, and ensuring prescription medications were labeled with the residents name and stored with the cap on the medication, and treatment carts locked when not in use. The facility identified two medication rooms, four medication carts and three treatment carts at the time of survey. Issues were found with one of one medication room observed, two of two medication carts observed and three of three treatments carts observed. The census was 52. Review of the facility's Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles policy, dated 10/28/19, showed: -Procedure: facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors; -Facility should ensure that medications and biologicals, once…

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

Based on observation, interview and record review, the facility failed to follow their policy on communicable disease by failing to ensure newly hired staff received the Mantoux tuberculin skin test (TST, used to test for latent tuberoses (TB) infection) two step as required for eight of 10 sampled staff hired within the past year. The census was 52. Review of the facility's tuberculosis testing and screening policy, revised 5/7/21, showed: -Purpose: To promote resident/associate safety and wellbeing by screening associates for TB and initiating appropriate follow-up; -New associates or volunteers who have been made a conditional offer shall be screened for the presence of infection through the following measures; -The facility should perform the TST two-step procedures; -Individuals with no documented history of TST skin test within the last 12 months will undergo the two step procedure. 1. Review of Activity Assistant F's employee file, showed: -Date of hire 11/4/21; -Employment ended 12/3/21; -No TST documentation provided. 2. Review of Certified Nursing Assistant (CNA) H'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 wore positioning devices as ordered to prevent loss in range of motion for one resident with limited range of motion. The staff failed to ensure one resident wore splint as ordered and/or document and address when the resident refused to wear the devices (Resident #17). For one of four residents sampled for restorative services. The census was 52. Review of the facility's Restorative Nursing policy, revised 8/7/21, showed: -The facility is responsible for providing maintenance and restorative programs as indicated by the resident's comprehensive assessment to achieve and maintain the highest practicable outcome; -Restorative Nursing Functions can be within one of the following categories: -Range of Motion (Active and Passive); -Splint or brace assistance; -Bed mobility; -Transfers; -Walking; -Dressing and/or grooming; -Eating and /or swallowing; -Amputation/prosthesis care; -Communication; -Toileting program; -Bladder Retraining. -The licensed nurse will conduct an evaluation on a routine…

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 are free of any significant medication errors for one resident (Resident #251) who missed a blood pressure medication for three days when it was not reordered from pharmacy timely. This resulted in the resident's blood pressure being elevated. The census was 52. Review of the facility's Administration of Medications policy, revised 7/14/21, showed -All medications are administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms; -The facility must ensure that its residents are free of any significant medication errors; -Medication error means the observed or identified preparation or administration of medications or biologicals are not in accordance with: -The prescriber's orders; -Manufacturer's specifications regarding the preparation and administration of the medication or biological; -Acceptable professional standards and principles, which apply to professionals providing services; -Significant medication error means one which causes the…

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

Based on interview and record review, the facility failed to maintain medical records on each resident in accordance with accepted professional standards and practices to ensure a resident's closed medical record was readily accessible for one resident. (Resident #301). This failure resulted in a delay of the survey process due to being unable to fully complete a complaint investigation. The census was 52. Review of Resident #301's medical record, reviewed on 3/25/22, showed an April 2020 laboratory result not found in the electronic medical record (EMR). During an interview on 3/25/22 at 2:00 P.M., administrator was asked to provide the resident's medical record. The administrator said the laboratory would not give the facility the requested information. The resident's full closed record was at their contracted medical records facility. She could get the records but the process would take a couple of days before the records arrive to the facility. During an interview on 3/28/22 at 1:00 P.M., the facility said they had still not received the requested medical record. During an…

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

Based on interview and record review, the facility failed to follow their staff vaccination policy for COVID-19. The facility had 66 employees. Of those 66, two employees were not fully vaccinated and without an exemption or medical delay, by the March 15, 2022 deadline. This resulted in 3.1% of facility staff who did not meet the requirement for staff vaccination. The facility did not have any positive resident cases in the four weeks preceding the onsite survey. Additionally, the facility failed to implement their policy related to additional precautions to mitigate the spread of COVID-19 for unvaccinated employees when two unvaccinated employees failed to wear an N-95 mask as directed by facility policy. The census was 52. 1. Review of the facility's Covid-19 (Sars-CoV-2) Vaccination Program Policy for Associates Policy, revised 2/23/22, showed: -Covid-19 Federal Mandate Secondary for Missouri includes: -(Initial Deadline) February 13, 2022 - Policies and procedures are developed and implemented for ensuring all facility staff, regardless of clinical responsibility or 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.