Sherbrooke Village

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide adequate treatment and services for two residents with pressure ulcers (wounds related to prolonged pressure on bony prominences) (Resident #2 and #13) and interventions to prevent pressure ulcers for one resident (Resident #23). The facility failed to provide ordered treatments and a timely wound consult for Resident #2. The facility failed to provide dressing changes when dressings were saturated, for Resident #13. The facility failed to provide Residents #13 and #23 with low air loss mattresses set to the correct settings, which would put the residents at risk for increased pressure on bony prominences. The sample size was 24. The census was 121. Review of the facility's Wound Management policy, dated 11/22, showed:-Policy: 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;Procedure: Wound Management:-…

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 foot care and treatment in accordance with professional standards of practice for two residents (Residents #60 and #98). The sample was 24. The census was 121.Review of the facility's Podiatry (foot specialty) Services policy, revised 2/16/26, showed:-Policy: The facility will assist in arranging for residents as needed;-Responsibility: Social Worker (SW) and Licensed Nurse;-Procedure: On admission and as needed, the Licensed Nurse evaluates feet and toenails for any abnormalities. The Licensed Nurse will notify the resident's medical provider of any needs for podiatry services and obtain and order for podiatry consultation. The Licensed Nurse will notify Social Services (SS) of the need for arranging podiatry services. SS will arrange for podiatry services, including transportation if needed. The Administrator will engage the services of a properly licensed podiatrist to serve facility residents. 1. Review of Resident #60'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 staff failed to use a gait-belt during a transfer for one resident (Resident #93). The sample size was 24. The census was 121. Review of the facility's Gait Belt Transfer policy dated 10/22, showed:-Policy: The Facility will utilize a Gait Belt for Residents who require one assist with Transfer to promote safety during Resident Transfers;-Responsibility: Nursing Assistants, Licensed Nurses (Licensed Practical Nurse (LPN) and Registered Nurses (RN), Nursing Administration, Assistant Director of Nursing (ADON) and Director of Nursing (DON);-Procedure:--Place Gait Belt around the Resident's waist over their clothing with the buckle forward;--Buckle/Fasten the Gait Belt;-- Slide open hand below belt to ensure the Gait Belt is snug but not too tight;-- Position your body close to the Resident; Face to Face;--Transfer Resident by firm grip on the Gait Belt with an underhand grip. Review of Resident's #98's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/24/26,…

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

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #74) with an external urinary collection device (a noninvasive external tube that drains the urine from the bladder) had appropriate physician orders to include catheter care instructions and monitoring. The sample was 24. The census was 121.Review of the facility's Lippincott Nursing Procedure Book, External Urine Collection Device Use, ninth edition, page 324, published 9/2/22, showed:-External urine collection device serves as an alternative to indwelling urinary catheters (sterile tube inserted into the bladder to drain urine) in cooperative residents who don't have signs of urinary retention;-An external urine collection device designed for male residents consist of a condom catheter or other device secure to the shaft of the penis and connected to a leg bag or drainage bag;-Complications are commonly due to equipment malfunction or trauma from improper application and removal can include penile irritation, skin breakdown, swelling, ischemic (dead) tissue loss and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to be free from medication errors of less than 5%. The facility's medication error rate was 11.11% with three errors out of 27 opportunities observed. Staff failed to monitor one resident's blood pressure (BP) prior to administration of Midodrine (a medication to treat low BP) (Resident #86). Staff also used improper technique and failed to follow the facility's policy when they instilled eyedrops for two different types of eye medications without pausing in between types of eyedrops, for one resident (Resident #92). The sample was 24. The census was 121. Review of the facility's Physician Orders policy dated 9/22, showed:-Policy: To provide guidance and ensure physician orders are transcribed and implemented in accordance with Professional Standards, State & Federal Guidelines.-Responsibility: Licensed Nurses, Nursing Administration, & Director of Nursing;-Physician Orders shall be provided by Licensed Practitioners (Physicians, Nurse…

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

Based on observation, interview, and record review, the facility failed to maintain medical records that were complete and accurately documented in accordance with acceptable professional standards and practices when staff documented treatments as completed when they had not been administered for one resident (Resident #23). The sample was 24. The census was 121. Review of Resident #23's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/30/26, showed:-Cognitively intact;-Diagnoses included dementia, muscle weakness, and quadriplegia (paralysis of all four limbs and the torso). Review of the resident's physician's order summary (POS), dated April 2026, showed:-An order, dated 1/5/26, for wound to right great toe. Morning shift, cleanse with wound cleanser, pat dry and apply dry dressing every 3 days until healed;-An order, dated 2/8/26, to change oxygen tubing weekly on Sunday evening shift;-An order, dated 3/10/26 for oxygen at 3 liters (L) via nasal canula (NC) as needed. Review of the resident's 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 Certified Nurse Aides (CNAs) employed at the facility for more than a year received no less than 12 hours of in-service training per year, for two of five sampled employees. The census was 121.Review of the facility's Facility Assessment, dated 1/30/26, showed:-Staff Training/Education and Competencies:-Competencies covered annually:--Activities of daily living (ADLs);--Disaster planning;--Medication administration;--Measurements (vitals, intake, output);--Resident assessment;--Caring for people with dementia, Alzheimer's disease, and cognitive impairments;--Caring for people with mental and psychosocial disorders;--Non-pharmacological management of responsive behaviors;--Caring for residents with trauma/post-traumatic stress disorder (PTSD);-The facility assessment did not identify how many training hours were required annually for CNAs. 1. Review of CNA EE's employee record, showed:-Hire date 7/18/17;-On 4/6/26, the first day of survey, CNA EE completed 15.5 hours of training between 4:25 P.M. and 6:20 P.M. 2.…

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

Based on observation, interview and record review, the facility failed to ensure one resident's (Resident #1's) feet were free from dry skin and failed to ensure skin assessments were accurate. The facility also failed to address the resident's foot care needs on the care plan. The sample was four. The census was 92. Review of the facility's skin integrity policy, dated 7/5/25, showed: -Purpose: To establish best practice guidelines for skin integrity monitoring and maintenance to reduce potential risk of skin breakdown where clinically appropriate; -Policy: Skin evaluations shall be completed upon admission and routinely, as per the care plan, to monitor skin integrity. Skin integrity risk factors will be evaluated upon admission and routinely, as per the care plan. Appropriate interventions will be initiated based on the risk factors identified. Lotion and moisture barrier products shall be available and applied as per the care plan. Minimize, as much as possible, any friction or vigorous rubbing of the skin while providing care. Any skin abnormalities noted shall be communicated…

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 immediately report an allegation of injury of unknown origin to the Department of Health of Senior Services (DHSS) within the required two-hour time frame, when Resident #1 wandered onto another unit, wearing only a brief, with a cord tied around his/her waist and a bloodied face. The sample was two. The census was 74. Review of the facility's Abuse Prevention policy revised [DATE], showed: Alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source are reported immediately, but not later than two hours after the allegation is made if the events that caused the allegation result in serious bodily injury. If the events that cause the allegation do not involve abuse and do not result in serious bodily injury, are reported immediately, but not later than 24 hours after the allegation is made, to the administrator of the facility and to other officials (including State Survey Agency). Review of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to have a licensed Administrator, who was legally responsible for establishing and implementing policies regarding the management and operation of the facility. This had the potential to affect all residents of the facility. The census was 128. The Interim Administrator was notified on [DATE] of the Past Non-Compliance. The Director of Business Operations (DBO) filed and received a Temporary Emergency License (TEL). The deficiency was corrected on [DATE]. Review of Administrator A's State of Missouri Nursing Home Administrator's License showed it was valid through [DATE]. Review of the DBO's cover letter for application of licensure/TEL application, dated [DATE], showed: -DBO had a previous TEL which was granted in [DATE]; -The application was dated [DATE]; -The receipt for Board of Nursing Home Administrators (BNHA) application for licensure was dated [DATE]. Review of an email from the BNHA to the DBO, dated [DATE], showed, Our office is waiting on 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 ensure newly hired employees were screened to determine the presence of a federal indicator (used to identify individuals found to have abused, neglected, or misappropriate resident property) with the Nurse Aide (NA) Registry for three of 10 sampled employees hired since the last survey. The facility hired at least 57 new employees since the last survey. The census was 88. Review of the facility's Abuse Prevention policy, approved 6/2022, showed: -Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms; -Policy Interpretation and Implementation: The community's goal is to achieve and maintain an abuse free environment. As part of the resident abuse prevention program, the administrator will provide a safe resident environment and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide and offer snacks at bed time, when snacks were only offered mid-day, between lunch and dinner, and not at bedtime. The census was 88. During an interview on 6/20/24 at 11:53 A.M., the Dietary Manager said breakfast was served at 7:30 A.M., lunch was served at 12:30 P.M. and dinner was served at 5:30 P.M. During a group interview on 6/24/24 at 1:55 P.M., eight residents, who represented the resident counsel, said the facility did not offer snacks anymore. One resident said they got nothing to eat after 5:00 P.M., his/her sugar was low the other night, and he/she was given some pudding. The facility would give residents a snack if their blood sugar was low. During an interview on 6/25/24 at 3:14 P.M., the Activity Director said they pass snacks at 3:00 P.M., and it's called [NAME]. It was pretty much every day unless they had socials. [NAME] was at 3:00 P.M., and they take the cart around and hand out snacks, drinks and talk to the residents. If…

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 infection control and prevention practices when staff brought the treatment cart into an isolation room and did not clean and disinfect the cart before taking the cart into another resident's room. In addition, staff failed to perform hand hygiene between glove changes, disinfect a clean field, and disinfect scissors for one resident during wound care (Residents #61 and #238). Staff failed to wear appropriate personal protective equipment (PPE), in accordance with the facility's policy, during high-contact activities with residents on enhanced barrier precautions (EBP, precautions for use during high-contact resident care activities for residents infected with a multidrug-resistant organism (MDRO, microorganisms that are resistant to one or more classes of antimicrobial agents) or any resident who has a chronic wound and/or indwelling medical device) for three residents (Residents #84, #240 and #73). The sample was 19. The census was 88. Review of the facility's Transmission-Based Precautions…

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 notify one resident's (Resident #239) physician timely when there was change in the drainage from a surgical wound and when there was a change in the resident's blood pressure. The sample was 19. The census was 88. Review of the facility's Clinical Protocol: Guidelines for Notifying Health Care Providers (Physicians) of Clinical Problems Policy, dated last approved 1/23, showed: -Purpose: These guidelines are to help ensure that 1) medical care problems are communicated to the health care provider, efficient and effective manner and 2) all significant changes in resident status are assessed and documented in the medical record; -Immediate Notification - Immediate implies that notification should occur as soon as possible, the health care provider or alternate is informed at the time of the event. Immediate notification is used when the resident has sign or symptom that is acute or sudden in onset and a marked change in relation to usual…

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 meet professional service standards when staff did not clarify medication orders and documented the same medication as given in multiple forms and duplicated doses, for one resident (Resident #67). In addition, the facility failed to follow physician orders when staff failed to send one resident (Resident #238) out to the hospital timely. The sample was 19. The census was 88. 1. Review of Resident #67's medical record, showed: -Diagnoses included Alzheimer's disease, unspecified dementia, and gastroesophageal reflux disease (GERD, heart burn); -An electronic physician order dated 10/21/22, for pantoprazole (used to treat heartburn) 40 milligram (mg) tablet delayed release, by mouth (PO), twice a day (BID), for GERD; -A paper chart physician order dated 10/27/22, for pantoprazole 40 mg tab, 1 tablet PO, BID, for GERD; -A paper chart medication administration record (MAR) dated 6/13/24, showed discontinue pantoprazole 40 mg tab, see new…

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

Based on interview and record review, the facility failed to obtain a stop date of 14 days or less on an as needed (PRN) psychotropic medication (a chemical substance that changes brain function and results in an alteration in perception, mood, consciousness, or behavior) for one resident (Resident #76). The sample size was 19. The census was 88. Review of the facility's Psychotropic Drugs policy, dated November 2022, showed: -Psychotropic medications may be considered for residents but only after medical, physical, functional psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed; -Psychotropic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review; -Residents will only receive psychotropic medications when necessary to treat specific conditions for which they are indicated and effective; -Psychotropic medications requirements apply to the four drug categories; (antipsychotic, antidepressant, antianxiety and hypnotic)…

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 five medication/treatment carts and two medication rooms. Three of the five carts and both medication rooms were checked for medication storage. Issues were found in both medication room medication refrigerators. Staff failed to discard an expired bottle of Pantoprazole suspension (used to treat heartburn) for one resident (Resident #67) and failed to date an opened vial of tuberculin purified protein derivative (PPD, used to diagnose silent (latent) tuberculosis (TB) infection) solution. In addition, the staff failed to check the refrigerator temperatures and keep the log sheets updated. The census was 88. Review of the facility's Storage of Medications policy, dated 12/2017, showed: -The nursing associates shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner; -The community shall not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to evaluate and assess one resident after falls and also failed to provide adequate supervision on the facility's memory care unit. Staff did not complete documentation of two falls for one resident (Resident #4) and left unsupervised medications next to one resident (Resident #5) in the dementia/memory care dining room. The sample was five. The census was 80. Review of the facility's Fall policy, revised July, 2023, showed: -The purpose of this procedure is to provide guidelines for evaluation of a resident in the event a fall occurred and to assist associates in identification of potential causes of the fall; -The [NAME] Fall Risk Assessment form (fall risk evaluation) should be utilized to complete the evaluation of the resident's potential for falls during the admission process; -The [NAME] Fall Risk Assessment form should be completed quarterly, with significant change, and after every fall; -If a resident sustains a fall, or is found 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.

Based on interview and record review, the facility failed to ensure a licensed administrator was employed at the facility as required by the Missouri Board of Nursing Home Administrators (MBNHA). The census was 70. Review of the MBNHA website, showed the facility had no licensed Administrator after 8/10/23. During an interview on 8/22/23 at 12:13 P.M., the Regional Executive Director (RED) said the facility has not had an Administrator since 8/10/23, when the previous Administrator stepped down. The facility contacted the MBNHA and thought they understood the regulation to say a facility could go up to ten days without an Administrator but they now understand that was incorrect. The RED said the facility cannot operate without an Administrator and the company should have contacted an agency to obtain a temporary Administrator as soon as it was determined the facility did not have an Administrator.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide reasonable accommodation of individual needs and preferences for one resident (Resident# 1), when two Certified Nurse Aides (CNAs) physically forced the resident to get into bed against his/her expressed wish to remain in his/her wheelchair and he/she resisted their efforts to lift him/her out of the wheelchair. The census was 70. Review of the facility's undated resident rights protocol, showed that residents of nursing homes have rights guaranteed by the federal Nursing Home Reform Law. The law requires nursing homes to promote and protect the rights of each resident and stresses individual dignity and self-determination. Residents have the right to a dignified existence; to be treated with consideration, respect and dignity, recognizing each resident's individuality. They have the right to exercise their rights without interference, coercion, discrimination or reprisal. Their rights include living in a homelike environment. Review of the…

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

Based on observation and interview, the facility failed to ensure all medications were behind at least one locked door or cabinet when several vials of insulin medication were found in an unlocked, white miniature refrigerator, in the nurse's work station in 200 hall of the facility. The census was 70. Observation on 8/22/23 between 10:50 A.M. and 12:30 P.M., of the nurse's work station on the 200 hall, inside the small white refrigerator, showed the following: -Four unopened Basaglar KwikPen (disposable, single-patient-use prefilled insulin pen), 100 units/milliliters; -One opened Basaglar KwikPen, with an unknown amount of insulin inside the pen; -One full box of tuberculin purified protein (indicated to aid diagnosis of tuberculosis infection); -One opened box of arfomterol (inhalation medication used to control wheezing, shortness of breath, coughing, and chest tightness). During an interview on 8/22/23 at 12:00 P.M., the Director of Clinical Services said the refrigerator should be locked and she was unaware it was unlocked. During an interview on 8/22/23 at 12:12 P.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.

Based on interviews and review of facility documentation, the facility failed to ensure the quality assessment and assurance committee attendees included the Medical Director or Designee. This failure had the potential to affect all 93 residents who currently live in the facility. Review of the document titled Quality Assurance and Performance Improvement (QAPI) Program, dated 09/2020, revealed at a minimum the following individuals serve on the committee: Administrator, Director of Nursing, Medical Director, Director of Quality, Infection Preventionist, Two other associates, Others as deemed necessary. During review of the QAPI attendance records 01/2022 through 09/2022 the Medical Director was not listed as attending. During an interview with the Director of Nursing (DON) and the Administrator on 10/27/22 at 12:54 PM, the Administrator stated the nurse managers, the social worker, activities director, therapy director, dietary manager, Executive Director, and Associate Engagement Advisor all attend the monthly QAPI meeting. The Administrator stated the Medical Director does not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed notify the physician when physician's orders for medications were not followed for three of 19 sampled residents (Resident (R) 52, 65, and 294) and three supplemental residents (R10, R57, and R240). Routine medications were not administered for R52 and R57. Medications were not administered on the day of admission to the facility per physician's orders for R10, R240, R294, and R65. 1. Review of R294's Profile Face Sheet, provided by the facility, revealed R294 admitted to the facility on [DATE] with diagnoses including aftercare following joint replacement surgery, acute on chronic diastolic (congestive) heart failure (CHF), type 2 diabetes mellitus without complications, unspecified atrial fibrillation, and presence of automatic cardiac defibrillator. Review of the Physician's Orders for 10/27/22 Signed Only, provided by the facility revealed the following relevant orders were entered into the electronic medical record (EMR) on 10/05/22 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and facility policy review, the facility failed to ensure physician's orders were followed for the oxygen flow rate (3-4 liters), the nasal cannula oxygen tubing was monitored for occlusions/kinks, and the oxygen humidifier maintained a sufficient water level (empty) and/or provide respiratory treatments for two of two residents (Resident (R) 293 and R10) sampled for oxygen administration in a total sample of 26 residents. The facility's deficient practice increased residents' potential risk for respiratory complications, including respiratory distress. 1. Review of facility provided policy titled Oxygen Administration, revised 10/18, revealed the purpose of this procedure is to provide guidelines for safe oxygen administration, verify physician's order for this procedure, observe the resident periodically, check the tubing connected to the oxygen and the concentrator to assure that it is free of kinks, and to be sure there is water in the humidifying jar and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of facility policy, the facility failed to provide routine drugs and biologicals to residents for three of 19 sampled residents (Resident (R) 52, 65, and 294) and three supplemental residents (R10, R57, and R240). Nursing staff routinely entered orders for new admissions to start the following day resulting in evening medications not being administered the night of admission. Additionally, the facility did not have a system in place to identify that medications were unavailable in advance, removing the opportunity to have medications delivered and avoid missed administration. The facility's pharmacy was unable to deliver STAT (immediate) medications. Review of the facility's policy, Pharmacy Services - Role of the Provider Pharmacy, dated 06/2022 in pertinent parts stated, The community shall have a written agreement with a provider pharmacy to provide regular and reliable pharmacy services to residents, including medications. The provider pharmacy 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 interview and policy review, the facility failed to have an effective Quality Assessment and Performance Improvement (QAPI- a program that enables the facility to evaluate and improve the quality of resident care and services through data collection, staff input, and systems review) program when deficient practice related to pharmacy services was identified and the facility did not identify appropriate plans to correct the identified practice and monitor for improvement. This deficient practice resulted in an ineffective QAPI program necessary to improve the quality of care provided to its residents and improve facility systems. Review of the facility's Quality Assurance and Performance Improvement (QAPI) Program, dated 09/2022 revealed, this community shall maintain an ongoing, comprehensive, data-driven, community-wide Quality Assurance and Performance Improvement (QAPI) program that focuses on the outcomes of quality of care and quality of life goals. The QAPI program has been developed with five strategic elements in mind. 1. The program is ongoing and comprehensive. 2.…

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

Based on interview and record review, the facility failed to inform residents and families when three residents (Resident (R) 8, R69, and R241) tested positive for COVID-19 on 10/23/22. Review of a document provided by the facility titled Procedure: COVID-19 Infection and Prevention Guidelines, dated 10/2022, revealed -Notifications of Residents, Resident Representatives, Associates; -Report infections, COVID-19 positive cases by 5 P.M. the next day after a positive confirmation to resident and resident representatives. Review of a document provided by the facility titled Positive Covid Residents, undated, revealed R8, R69, and R241 tested positive for COVID-19 on 10/23/22. Review of the Resident and Family Member Letter: Current Resident and Staff COVID-19 Case Statistics, provided by the facility, dated 10/24/22, revealed the current number of residents who are COVID-19 positive in our community is 0. Review of the Resident and Family Member Letter: Current Resident and Staff COVID-19 Case Statistics, provided by the facility, dated 10/26/22, revealed the current number 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, interviews, record reviews, and review of facility policy, the facility failed to ensure one of 26 sampled residents (Resident (R) 293) had a physician's order and was assessed and care planned for the self-administration of medications prior to self-administration of medication by the resident. Review of facility provided policy titled Self-Administration of Medication, dated 12/21, revealed Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. The nurse will complete the self-administration of medication assessment. If the nurse and physician determines that a resident can safely self-administer an order will be obtained for self-administration of medication. The resident person-centered care plan will be updated to reflect the wishes to self-administer medication. Nursing will monitor the medication administration record (MAR) appropriately noting that the doses were…

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 interviews, record review, and policy review, the facility failed to implement policies and procedures for ensuring all alleged violations involving abuse were reported immediately, but not later than two hours after the allegation was made, to the State Survey Agency for one of five residents (Resident (R) 58) reviewed for abuse. Review of the facility's Abuse Investigation and Reporting, policy last revised 07/2022 revealed all reports of resident abuse and/or mistreatment shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by community management. If an incident or suspected incident of resident abuse is reported, the Administrator or designee will assign the investigation to an appropriate individual . upon conclusion of the investigation, the investigator will record the results of the investigation on approved documentation forms and provide the completed documentation to the Administrator or designee. All alleged violations involving abuse will be reported to the Administrator or designee 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 interviews, record review, and policy review, the facility failed in response to allegations of abuse to maintain documented evidence that all violations were thoroughly investigated for one of five residents (Resident (R) 58) reviewed for abuse. Review of the facility's Abuse Investigation and Reporting, policy last revised 07/2022, revealed all reports of resident abuse and/or mistreatment shall be thoroughly investigated by community management. If an incident or suspected incident of resident abuse is reported, the Administrator or designee will assign the investigation to an appropriate individual. The individual conducting the investigation will, at a minimum interview the person(s) reporting the incident, interview any witnesses to the incident, interview associate members, on all shifts, who have had contact with the resident during the period of the alleged incident, and interview the resident's roommate, family members, and visitors. Upon conclusion of the investigation, the investigator will record the results of the investigation on approved documentation forms…

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, and policy review, the facility failed to ensure treatments were administered as ordered for one of one resident (Resident (R) 65) reviewed for non-pressure skin conditions in the sample of 26 residents and failed to ensure the medical record was updated with skin integrity identification changes or the development and implementation of care plan interventions regarding a catheter leg strap for one of one resident (Resident (R) 291) reviewed for skin integrity in a total sample of 26 residents. 1. A policy for following physician orders was requested and none was provided. Review of R65's undated Profile Face Sheet, provided by the facility, indicated he/she was admitted [DATE] with diagnoses including fracture of left tibia (shin bone) and infection following a surgical procedure. Review of R65's admission Minimal Data Sheet (MDS), provided by the facility, with an Assessment Reference Date (ARD) of 09/25/22 revealed a Brief Interview for Mental Status (BIMS)…

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, interviews, record review, and facility policy review, the facility failed to ensure one of one resident (Resident (R) 291) reviewed for urinary catheter had a leg strap (stat lock) to reduce friction and movement of R291's indwelling urinary catheter at the insertion site in a total sample of 26 residents. The facility's deficient practice had potential to injure R291's urinary tract system. Review of facility provided policy titled Catheter Care, Urinary, dated 01/22, revealed Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh) Review of [NAME] CARE, a manufacture's brochure titled StatLock Stabilization Device, undated, revealed the StatLock Foley Stabilization Device is a strap free device which secures the Foley catheter in place, stabilizes the catheter and reduces the likelihood of a sudden pull. Review of the Face Sheet, located in the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews, and review of the facility assessment, the facility failed to ensure clinical staff had chest tube skills and knowledge to provide chest tube care effectively and safely for one of one resident (Resident (R) 293) reviewed for care of a chest tube in a total sample of 26 residents. The facility deficient practice increased the risk of respiratory complications for R293. Review of the facility assessment with the implementation date of 08/13/21 revealed practices, frequent education, and re-education with all clinical and non-clinical staff. Education is provided in a variety of ways including immediate face to face education when resident needs change. Review of a facility provided document titled PleurX Pleural Catheter Kit, dated 08/15, revealed for Pleural Placement Only Sterile it is vital that caregivers are carefully instructed on how to use the kit to drain the pleural cavity. The person (s) responsible for drainage must be able to demonstrate they are capable of…

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

Based on observations, staff interviews, and record review, the facility failed to ensure residents who use psychotropic drugs received gradual dose reductions (GDR), if not contraindicated, and/or monitor specific behaviors for three of five residents (Resident (R) 64, R38, and R291) reviewed for unnecessary medications in a total sample of 26 residents. Review of facility policy titled, Psychotropic Medication, dated 07/2020, revealed, the health care practitioner and other associates will gather and document information to clarify a resident's behavior. A resident who used psychotropic medication will receive gradual dose reduction (GDR) and behavioral interventions. The pharmacist will report on the medication regiment review (MRR) and will submit recommendations to the physician and Director of Nursing (DON). The DON will ensure that recommendations are followed through which will not exceed 30 days. 1. During an interview and resident observation on 10/24/22 at 11:22 AM, R64 was pacing back and forth from his/her room to the nurses' station. R64 stated he/she was lost and did…

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.