St Peters Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to honor resident rights for one sampled resident (Resident #4), in a review of four sampled residents and for three additional residents (Residents #5, #6 and #7), by failing to allow them to choose their own wake up/get-up times. The facility census was 117. Review of the facility policy, Resident Rights, dated 2001, showed the following: -Employees shall treat all residents with kindness, respect and dignity; -Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents right to a dignified existence, to be treated with respect, kindness and dignity, self determination, exercise his/her rights as a resident of the facility and be supported by the facility in exercising his/her rights. 1. Review of the facility Night Shift Early Rise document, dated 05/29/25, and provided by the Assistant Director Of Nursing (ADON), showed it included a list of residents and their rooms numbers.…

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 direct care staff utilized Enhanced Barrier Precaution (EBP) (an infection control strategy that uses gloves and gowns during high-contact resident care to reduce the spread of multi-drug-resistant organisms (MDROs) when providing care and failed to ensure nursing staff washed their hands and changed soiled gloves after each direct resident contact and when indicated by professional standards of practice during care for one sampled resident (Resident #2), who had a gastrostomy tube (G-tube) feeding tube placed surgically into the stomach through the abdominal wall) and for one additional resident (Resident #8), who had a urinary catheter (flexible tube inserted into the bladder to drain urine from the body) in a review of four sampled residents and three additional residents. The facility census was 38. Review of the facility policy, Enhanced Barrier Precautions, last revised 12/2024 showed EBP's are utilized to prevent the spread…

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 Refer to event id MPKL12 Based on interview and record review, facility failed to make a prompt effort to resolve resident grievances (cause for complaint) and provide written documentation of responses related to the grievances for four sampled residents (Resident #1, #6, #8 and #9) when the family members of the residents requested a meeting with the administrator and department managers and filed grievances and the facility did not follow up or provide a plan for resolution to those grievances. The facility census was 116. Review of the facility policy for Filing Grievances/Complaints dated 4/2017 showed the following: -Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g. the State Ombudsman); -The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative; -Any resident, family member, or appointed 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 Refer to event id MPKL12 Based on interview and record review, the facility failed to provide four residents (Resident #1, #4, #5 and #8) sampled residents, the necessary care and services to maintain his/her highest practicable well-being when staff failed to provide incontinent care for Resident #1 and Resident #8 in a timely manner. Resident #8 had been up in a wheelchair from 7:30 A.M. until 4:45 P.M. without being taken to the bathroom. Resident #1 had been observed incontinent at 11:30 P.M. and was not provided care until 4:00 P.M. Resident #4 and Resident #5 were observed in their beds at 11:30 A.M. and had not been given a noon meal tray or offered any food or fluids until staff got the residents to the dining room for the supper meal at 5:00 P.M. The facility census was 116. Review of the facility policy for Assistance with Meals dated 3/2022 showed the following: -Residents shall receive assistance with meals in a manner that meets the individual needs of each resident: -Dining Room Residents: all…

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 Refer to event id MPKL12 Based on observation, interview, and record review, the facility failed to follow the Registered Dietician's recommendation and physician orders for prescribed interventions to address weight loss for five residents (Resident #1, #2, #3, #4, and #6) of 11 sampled residents. The facility also failed to educate staff on the interventions that were put in place and how to identify fortified foods to ensure residents received food ordered by the physician to prevent further weight loss. The facility census was 116. Review of the facility policy for Weight Assessment and Intervention dated 3/2022 showed the following: -Resident weights are monitored for undesirable or unintended weight loss or gain; -Residents are weighed upon admission and at intervals established by the interdisciplinary team; -Weights are recorded in each units weight record and chart and in the individual's medical record; -Any weight change of 5% or more since the last weight assessment is retaken the next day 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 Refer to event id MPKL12 Based on observation, interview and record review, the facility failed to ensure resident safety by failure to transfer one resident (Resident #8) as directed in his/her plan of care and failed to follow the facility policy for using a mechanical lift for the transfer. The facility failed to ensure one resident's (Resident #9's) safety when staff left the resident alone on the toilet and fell of 11 sampled residents. The facility census was 116. Review of the undated facility policy for Managing Falls and Fall Risk showed based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. Review of the facility policy for Safe Lifting and Movement of Residents dated 7/2017 showed: the following: -In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate…

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, document review, and facility policy review, the facility failed to ensure the dish machine operated at the correct temperature and equipment and surfaces were kept clean for one of one kitchen. This had the potential to affect 113 of 113 residents who received meals prepared in the facility. Findings include: Review of the facility's policy titled, Sanitation, dated 11/22, revealed The food service area is maintained in a clean and sanitary manner. 1. All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects .2. All utensils, counters, shelves and equipment are kept clean .5. Dishwashing machines are operated according to manufacturer's instructions. General recommendations for heat and chemical sanitization are . b. Low-Temperature Dishwasher (Chemical Sanitization): (1) Wash temperature (120°F [Fahrenheit]) . The policy did not address the temperature of the rinse cycle. Review of the kitchen cleaning schedule dated 12/15/24- 12/20/24, provided by the facility, revealed Walls…

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, record review, interviews, and facility policy review, the facility failed to provide a dignified dining experience for three of 20 residents (Resident (R) 68, R98, and R88) who resided on the memory care unit by standing to assist to feed R68 and R98; by failing to obtain an alternate meal in a timely manner for R88 when she refused what was served; and by failing to provide continuous dining service for one resident (R102) on the long term care unit of 30 sample residents. This failure had the potential to affect resident dignified dining experiences. Findings include: Review of the facility's policy titled Assistance with Meals, dated 03/22, revealed Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example: a. not standing over residents while assisting them with meals; b. keeping interactions with other staff to a minimum while assisting residents with meals; c. avoiding the use of labels when referring to residents (e.g., 'feeders);…

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, facility failed to make a prompt effort to resolve resident grievances (cause for complaint) and provide written documentation of responses related to the grievances for four sampled residents (Resident #1, #6, #8 and #9) when the family members of the residents requested a meeting with the administrator and department managers and filed grievances and the facility did not follow up or provide a plan for resolution to those grievances. The facility census was 116. Review of the facility policy for Filing Grievances/Complaints dated 4/2017 showed the following: -Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g. the State Ombudsman); -The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative; -Any resident, family member, or appointed resident representative may file a grievance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide four residents (Resident #1, #4, #5 and #8) sampled residents, the necessary care and services to maintain his/her highest practicable well-being when staff failed to provide incontinent care for Resident #1 and Resident #8 in a timely manner. Resident #8 had been up in a wheelchair from 7:30 A.M. until 4:45 P.M. without being taken to the bathroom. Resident #1 had been observed incontinent at 11:30 P.M. and was not provided care until 4:00 P.M. Resident #4 and Resident #5 were observed in their beds at 11:30 A.M. and had not been given a noon meal tray or offered any food or fluids until staff got the residents to the dining room for the supper meal at 5:00 P.M. The facility census was 116. Review of the facility policy for Assistance with Meals dated 3/2022 showed the following: -Residents shall receive assistance with meals in a manner that meets the individual needs of each resident: -Dining Room Residents: all residents will be encouraged…

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, record review, interview, and facility policy review, the facility failed to implement weight loss interventions and/or provide meal encouragement for one of eight residents (Resident (R) 95) reviewed for nutrition of 30 sample residents. This had the potential to cause further weight loss. Findings include: Review of the facility's policy titled, Nutrition (Impaired)/Unplanned Weight Loss, revised 09/12, provided by the facility, revealed 1. The staff and physician will identify pertinent interventions based on identified causes and overall resident condition, prognosis, and wishes. 1. The physician and staff will monitor nutritional status, an individual's response to interventions, and possible complications of such interventions (for example, additional weight gain or loss, nausea, or vomiting). Review of the facility's policy titled, Nutrition (Impaired)/Unplanned Weight Loss, revised 02/22, provided by the facility, revealed 5. The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of…

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

Based on observation, interview, and facility policy review, the facility failed to ensure the facility's dumpster area was kept cleaned and the container lids were kept closed when not in use for 115 census residents. This had the potential to attract rodents and other pests that could enter the facility. Findings include: Review of the facility's policy titled, Food-Related Garbage and Rubbish Disposal, revised 04/06, revealed 1. All garbage and rubbish containing food waste shall be kept in containers. 2. All garbage and rubbish containers shall be provided with tight-fitting lids or covers and must be kept covered when stored or not in continuous use .7. Outside dumpsters provided by garbage pick up services will be kept closed and free of surrounding litter. During an observation with the Dietary Manager (DM) on 12/17/24 at 3:18 PM, the dumpster container area, located adjacent to the kitchen's rear exit hall had two dumpsters for garbage and one dumpster for recycling. Two dumpster containers for garbage each had two separate top lids. Both lids on the dumpster containers 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 record review, interview, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure a discharge return anticipated (DCRA) Minimum Data Set (MDS) assessment was submitted timely for processing for one of one resident (Resident (R) 6) reviewed out of 30 sample residents. This failure had the potential to adversely affect care planning and care provision or payment to other facilities for any resident that may not have had a discharge assessment transmitted. Findings include: Review of the facility's policy titled, MDS Completion and Submission Timeframes, reviewed July 2017, revealed Policy Statement. Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. Policy Interpretation and Implementation. 1. The assessment coordinator or designee is responsible for ensuring that resident assessments are submitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines. 2. Timeframes for completion and submission 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 record review, interview, and facility policy review, the facility failed to develop a person-centered comprehensive plan of care with measurable goals and plans for two of six residents (Resident (R) 61 and R94) reviewed for psychoactive medication use of 30 sample residents. This failure had the potential to affect the ability for a physician to prescribe the lowest possible effective dose of psychoactive medications. Findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, revealed: Policy Statement. A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation .7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes . 1. Review of R61's admission Record from the electronic medical record (EMR) Profile tab showed a facility admission date of 11/15/24 with medical diagnoses that…

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 resident safety by failure to transfer one resident (Resident #8) as directed in his/her plan of care and failed to follow the facility policy for using a mechanical lift for the transfer. The facility failed to ensure one resident's (Resident #9's) safety when staff left the resident alone on the toilet and fell of 11 sampled residents. The facility census was 116. Review of the undated facility policy for Managing Falls and Fall Risk showed based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. Review of the facility policy for Safe Lifting and Movement of Residents dated 7/2017 showed: the following: -In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide toileting assistance when requested, which created the potential for discomfort and distress to one of 20 residents (Resident (R) 47) and failed to ensure an order was in place for catheters for one of four residents (R70) reviewed for catheters of 30 sample residents. This failure had the potential to cause discomfort and reoccurring urinary tract infections or other complications. Findings include: Review of the facility's policy titled, Activities of Daily Living (ADL), Supporting, dated 03/18, revealed Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with . elimination (toileting). Review of the facility's policy titled, Medication and Treatment Orders, dated 06/16, provided by the facility, revealed Orders for medications and treatments will be…

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

Based on interview, record review, and facility policy review, the facility failed to ensure there were documented indications for use of and that psychotropic medication efficacy was monitored for two of six residents (Resident (R) 61 and R94) reviewed for unnecessary medications or antipsychotic medication use of 30 sample residents. This failure had the potential to affect the ability for a physician to prescribe the lowest possible effective dose of medication. Findings include: Review of the facility's policy titled, Psychotropic Medication Use, revised July 2022, revealed: Policy Interpretation and Implementation. 1. A psychotropic medication is any mediation that affects brain activity associated with mental processes and behavior. 2. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: a. Anti-psychotics; b. Anti-depressants; c. Anti-anxiety medications; and d. Hypnotics .Psychotropic medication management includes a. indications for use; .d.…

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, record review, interview, and facility policy review, the facility failed to ensure food preferences were obtained and honored for one of one resident (Resident (R) 54) reviewed for food preferences of 30 sample residents. This failure had the potential to cause R54 not to maintain proper nutrition. Findings include: Review of R54's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 11/21/24, located in the MDS tab of the electronic medical record (EMR), revealed an admission date of 02/13/24 and had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R54 was cognitively intact, and had diagnoses of heart failure, unspecified atrial fibrillation, and coronary artery disease. Review of R54's Care Plan, dated 11/20/24 and located in the EMR under the Care Plan tab, revealed Nutritional Risk: Resident has the potential for altered nutrition and/or hydration status related to mechanically altered diet. Interventions included Cater to food preferences, and Food preference per resident choice. Review of R54'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.

Refer to event id 50SJ13 Based on observation, interview, and record review, the facility failed to serve food to the residents at an appetizing temperature. Residents who ate meals in their rooms said the food was cold when served most of the time. The facility census was 115.

Refer to event id 50SJ13 Based on interview and record review, the facility failed to inform five residents (Residents #5, #13, #14, #15, and #16) or their representatives, in a review of 16 sampled residents, of respiratory therapy services they may be charged for which were not covered under Medicare/Medicaid or by the facility's per diem rate, prior to receiving those services, when the facility charged the residents for respiratory therapy services. The facility census was 115.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to comply with state laws and designate a person as an administrator currently licensed in the state as a nursing home administrator. This had the potential to affect all facility residents. The facility census was 117. Review of the facility policy, Administrator, dated 3/2021, showed the following: -A licensed administrator is responsible for the day to day functions of the facility; -The governing board of this facility has appointed an administrator who is duly licensed in accordance with current federal and state requirements; -Should an administrator license expire, the facility has 10 days to have a fully licensed administrator step into the position; -In the absence of the administrator, the assistant administrator or director of nursing services was authorized to act in the administrator's behalf. Observation on [DATE] at 10:13 A.M., of the hallway leading to the entrance of the administrator's office showed the following: -A State of Missouri…

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

Based on interview and record review, the facility failed to designate one or more individuals, who was qualified by completing specialized training in infection prevention and control, as the Infection Preventionist (IP) responsible for the facility's Infection Prevention and Control Program. The facility census was 117. Review of the facility policy, Infection Prevention and Control Program, dated 12/2023, showed the following: -An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections; -The IPCP provides a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under contractual arrangement; -The IPCP is coordinated and overseen by an infection prevention specialist (Infection Preventionist); -Data gathered during surveillance is used to oversee infections and spot…

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

Based on observation, interview, and record review, the facility failed to ensure the planned menu, reviewed by the Registered Dietician, was followed and items listed on the menu served to the residents. The facility also failed to serve the correct serving sizes per the menu. The facility's census was 117. Review of the facility policy Food and Nutrition Services, dated 10/2017, showed the following: -Each resident is provided a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident; -Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident. 1. Review of the spread sheet signed by the Registered Dietician (RD), dated 4/17/24, showed the lunch meal was to include cheeseburger with French fries, relish plate, and ambrosia deluxe. The meal was to be served on 8/20/24. Review of the menu dated 8/20/24 showed the noon meal included: -Chicken [NAME] Soup; -Turkey burger; -Potato Wedges; -Apple cider slaw; -Double…

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 issue an appropriate discharge notice to one resident (Resident #4) of nine sampled residents. The facility failed to document an appropriate location to which the resident would be discharged , failed to ensure the physician documented in the resident's medical record the specific needs the facility could not meet, and failed to provide the explanation of the right to appeal to the state (the name, address and phone number of the state entity which receives appeal hearing requests). The facility census was 117. Review of the facility policy Discharge Summary and Plan, dated 12/2022, showed the following: -Every resident is evaluated for his/her discharge needs and has an individualized post discharge plan; -The post discharge plan is developed by the care planning/interdisciplinary team with the assistance of the resident and his/her family and includes: where the individual plans to reside, arrangements that have been made for follow up care and services, a description of the resident's stated discharge goals, what…

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 the water faucet in the food preparation area in the kitchen. The faucet would not turn off and water ran continuously at approximately half flow. The facility census was 117. Review of the facility policy Maintenance Service, dated 12/2009, showed the following: -The maintenance department was responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times; -Functions of maintenance personnel included but were not limited to maintaining the plumbing fixtures. Review of the facility Maintenance Request Log, dated 7/1/24, showed the following: -The Dietary Manager put in a work request for a sink in the prep area that was leaking; -The Maintenance Director marked the status of the leaking sink as done. Review of the facility Maintenance Request Log, dated 8/13/24, showed the following: -The Dietary Manager put in a work request for a sink in the prep area that did not have hot water; -The Maintenance Director marked the status of the leaking sink as done.…

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.

Refer to 50SJ12. Based on observation and interview, the facility failed to prepare and serve food under sanitary conditions. The staff failed to ensure the kitchen floors were free from food, debris and rodent feces, failed to ensure surfaces of equipment in the kitchen were free from rodent feces, failed to label and date food when opened, failed to appropriately store food, and failed to discard food items that were compromised including ice cream and apples. The facility census was 117.

Refer to 50SJ12. Based on observation and interview, the facility failed to maintain an effective pest control program to control the presence of rodents in the kitchen. The facility census was 117.

Based on interview and record review, the facility failed to provide appropriate services to attain the highest practical well-being for one resident (Resident #2), with a diagnosis of dementia, in a review of four sampled residents. Facility staff identified the resident had behaviors affecting the resident and other residents, however, did not evaluate and implement further approaches to address the resident's care needs related to his/her diagnosis of dementia. Resident #2 had an increase in behaviors which resulted in the administration of anti-anxiety IM (intramuscular) medication and psychotropic medication (a psychoactive drug taken to exert an effect on the chemical makeup of the brain and nervous system) without trying alternative interventions first. The resident's physician placed an order for the resident to be seen by psychiatry due to the increase in behaviors on 6/24/24 and the facility failed to schedule the resident for the consultation. The resident continued to have behaviors and subsequent increase in administration by staff of psychotropic medications as 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 observation and interview, the facility failed to prepare and serve food under sanitary conditions. The staff failed to ensure the kitchen floors were free from food, debris and rodent feces, failed to ensure surfaces of equipment in the kitchen were free from rodent feces, failed to label and date food when opened, failed to appropriately store food, and failed to discard food items that were compromised including ice cream and apples. The facility census was 117. Review of the facility policy for Sanitization dated 11/2022 showed: -The food service area is maintained in a clean and sanitary manner; -All kitchen, kitchen areas, and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects. There was no policy provided regarding dating and labeling of foods or food storage. Review of the undated facility policy for Pest Control showed: -Our facility shall maintain an effective pest control program; -This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents; -Garbage and…

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

Based on interview and record review, the facility failed to inform five residents (Residents #5, #13, #14, #15, and #16) or their representatives, in a review of 16 sampled residents, of respiratory therapy services they may be charged for which were not covered under Medicare/Medicaid or by the facility's per diem rate, prior to receiving those services, when the facility charged the residents for respiratory therapy services. The facility census was 115. The facility did not provide a policy for the respiratory therapy department or to outline the responsibilities of the respiratory therapist. 1. Review Resident #5's face sheet showed the resident's payer source was private pay and Medicare Part B. Review of the resident's Physician Orders, dated 6/19/24, showed an order for respiratory therapy/nursing to perform flutter valve-chest wall manipulation to facilitate lung function three times a day. (The ordered therapy ended on 8/19/24.) Review of the resident's billing statement from the facility, dated 8/31/24, showed the following: -Charges on the statement were from 7/1/24 to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff provided five residents (Residents #1, #2, #3, #4, and #7), who were unable to perform their own activities of daily living, in a review of 13 sampled residents, the necessary care and services to maintain good oral hygiene. The facility census was 113. Review of the facility policy for Activities of Daily Living (ADL) dated revised on 3/2018 showed: -Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs); -Residents who are unable to carry out ADL's independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene; -Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing,…

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.

This deficiency is uncorrected. For previous examples, see the Statement of Deficiencies dated 8/21/24. Based on observation, interview, and record review, the facility failed to ensure the planned menu, reviewed by the Dietary Consultant, was followed and items listed on the menu were served to the residents. The facility also failed to serve the correct serving sizes per the facility diet spreadsheet. The facility's census was 115. Review of the facility untitled policy, dated 2023, showed the following: -Food will be served according to the posted menu. If the menu changes residents will be notified as reasonably able; -Each wait staff should serve one table completely before starting to serve the next table. 1. Review of the menu dated 9/23/24 showed the noon meal included: -Tossed salad with dressing; -Baked glazed ham; -One half of a baked sweet potato; -Green bean casserole; -Dinner roll with margarine; -Assorted desserts. Review of the facility diet spread sheet, dated cycle day 23, for the noon meal showed the following: -Tossed salad with dressing, one half cup; -Country…

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 serve food to the residents at an appetizing temperature. Residents who ate meals in their rooms said the food was cold when served most of the time. The facility census was 115. The facility did not provide a policy for food temperatures upon request. Review of the dietary cook job description, dated 10/2016, showed the following: -The cook was responsible to record food temperatures for each meal; -The cook was to manage and operate the kitchen in the absence of the dietary supervisor. Review of the facility policy Tray Line Food Temperatures, showed the following: -Hot foods should be 135 degrees Fahrenheit or greater; -Cold Foods should be 41 degrees Fahrenheit or less: -Each day had three columns to take food temperatures (before, during, and after each meal served). 1. Review of the facility Tray Line Food Temperatures, dated 9/15/24 through 9/17/24, showed the following: -On 9/15/24 no food temperatures were taken during or after the breakfast meal was served; -On 9/15/24 no food temperatures 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a policy for Enhanced Barrier Precautions (EBP-Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multi drug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices) and failed to ensure staff's adherence to use of personal protective equipment (PPE) for four of thirteen residents (Resident #8, #9, #10, and #11) who met criteria to be on enhanced precaution isolations. The census was 113. Review of the facility policy for Isolation - Categories of Transmission-Based Precautions dated September 2022 showed: -Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible…

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 maintain an effective pest control program to control the presence of rodents in the kitchen. The facility census was 117. Review of the facility's undated policy for Pest Control showed the following: -Our facility shall maintain an effective pest control program; -This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents; -Garbage and trash are not permitted to accumulate and are removed from the facility daily. 1. Observation on 7/23/24 at 2:14 P.M., in the main kitchen showed the following: -A stainless steel preparation table in the kitchen in front of the steam table with numerous black pellets that resembled rodent feces on the bottom rack of the table. Staff used the table to store and prepare food; -Behind the table on the floor there was a copious amount of rodent feces among packets of condiments and food particles; -A cart that contained covers for plates was dirty with food particles and rodent feces noted on the cart; -French fries and food…

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 and services in accordance with professional standards of practice for three resident (Resident #2, Resident #4 and Resident #10) of 13 sampled residents when staff failed to ensure medications were not left in resident rooms, and residents had an order to keep medications at bedside. The facility census was 113. The facility did not provide a policy for medications at the resident's bedside. 1. Review of resident #2 quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 2/22/24 showed: -Able to make self understood and able to understand others, difficulty with some decision making; -Requires staff assistance with Activities of Daily Living (ADL's); -Diagnoses of heart disease, hypertension, diabetes, stroke, dementia and depression. Review of the Physician Order Sheet (POS) for June 2024 showed an order for Nystatin External Powder, apply to abdominal folds…

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

Based on interview and record review, the facility failed to provide appropriate services to attain the highest practical well-being for one resident (Resident #2), with a diagnosis of dementia, in a review of four sampled residents. Facility staff identified the resident had behaviors affecting the resident and other residents, however, did not evaluate and implement further approaches to address the resident's care needs related to his/her diagnosis of dementia. Resident #2 had an increase in behaviors which resulted in the administration of anti-anxiety IM (intramuscular) medication and psychotropic medication (a psychoactive drug taken to exert an effect on the chemical makeup of the brain and nervous system) without trying alternative interventions first. The resident's physician placed an order for the resident to be seen by psychiatry due to the increase in behaviors on 6/24/24 and the facility failed to schedule the resident for the consultation. The resident continued to have behaviors and subsequent increase in administration by staff of psychotropic medications as 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 observation and interview, the facility failed to comply with state laws and designate a person as an administrator currently licensed in the state as a nursing home administrator. This had the potential to affect all facility residents. The facility census was 118. The facility did not provide a policy for the requirements of the facility administrator. Observation on 3/28/24 at 8:55 A.M. of the facility lobby and hallway leading to the administrator's office showed the following: -The facility license to operate as a long term care facility and different associations memberships; -No current administrator's license. During an interview on 3/28/24 at 8:55 A.M. the acting administrator said the following: -He had been at the facility for about a week acting as the administrator; -He did not hold a license to be an administrator in the state of Missouri; -He had not contacted the state licensing board or the state regulatory agency for a temporary license until he could sit for the the state license exam; -Neither he or his company was aware that he could have applied for a…

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

Based on observation, interview, record review, and policy review, the facility failed to ensure the kitchen was maintained in a sanitary manner to prevent the potential spread of food borne illness to 115 residents who resided in the facility and were able to consume meals. Concerns included: proper dating and labeling of all food items, providing proper training to all staff handling food, and proper serving temperatures were maintained when food was served to residents. Findings include: Review of the facility's policy titled, Refrigerator and Freezer Storage, reviewed/revised date 11/2017, revealed, Foods will be stored in their original container or a NSF [National Sanitation Foundation] approved container or wrapped tightly in moisture-proof film, foil, etc. Clearly labeled with the contents and the use by date. Review of the facility's policy titled, Temperature Control, reviewed/revised date 11/2017, Revealed, Internal temperatures should be reached to assure food safety .Foods not in proper range will be reheated or chilled further .Foods may also be cooked or reheated in 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 record review, interview, and policy review, the facility failed to obtain a physician's order to include the type and size of the indwelling catheter, and criteria for changing the indwelling catheter for one of two residents (Resident (R) 104) reviewed for urinary catheters in a total sample of 33 residents. This failure has the risk for complications, such as urinary trauma or infection, for any resident with an indwelling urinary catheter. Findings include: Review of R104's undated admission Record, located in the Electronic Medical Record (EMR) under the Face Sheet tab revealed R104 was admitted from the hospital to the facility on [DATE] and had a diagnosis of bladder neck obstruction. Review of R104's September 2022 Physician Orders located in the EMR under the Orders tab revealed there was no physician's order for an indwelling catheter for R104. Review of the Criteria for Indwelling Catheter provided by the Nurse Practitioner (NP) documented R104 required an indwelling catheter for bladder…

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 credit all interest earned on residents' funds to the 49 residents the facility held resident funds for. Further review showed the facility failed to prevent one resident (Resident #101) from overspending his/her account and using other resident monies. The facility census was 117. Review of the facility Bookkeeping Manual, section: for resident trust, subject: interest allocation, dated 08/07, showed interest earned must be credited to each resident's account. Review of the facility Bookkeeping Manual, section: for resident trust, subject: resident trust fund balances, dated 08/07 and revised 10/10, showed the following: -It was recommended a report be printed each day to be able to determine the level of funds a resident had available; -The balance on the report will be a positive number unless the resident has overdrawn their account. 1. Record review of the facility's resident fund bank statements showed the following: -July 2019 statement showed the interest bearing account earned $1.62, 0.38 cents was withheld;…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain closets in good repair, maintain the memory care free of a mold-like substance, and maintain a toilet in good repair. The census was 117. 1. Observation on 8/14/19 at 1:07 P.M., showed the toilet seat in the bathroom in resident room [ROOM NUMBER] was held on by only one bolt and was very loose. During interview on 8/14/19 at 1:07 P.M., Resident #409 said he/she has told the facility about the loose toilet seat. It has been that way for two to three weeks. The toilet seat pinched him/her every time he/she sat on it. Observations on 8/14/19 between 9:25 A.M. and 3:32 P.M., showed the following: -In resident room [ROOM NUMBER], four patches of unmatched paint on the wall. The areas were approximately 1 foot by 3 inches, 1 foot by 8 inches, 1 foot by 6 inches, and 1 foot by 1.5 feet; -In the memory care mechanical room, a black, mold-like substance on a 4-foot section of the wall; -In the memory care nurses' station, a black, mold-like substance…

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 staff failed to ensure a Quarterly Minimum Data Set (MDS), a federally mandated resident assessment completed by the facility staff, was completed no less than once every three months for four of 26 sampled residents (Resident #4, #30, #25, and #107) and for three additional residents (Resident #7, #9, and #6) . The facility census was 117. During an interview on 8/16/19 at 5:46 P.M., the MDS coordinator said the facility followed the RAI process for completion of resident's quarterly assessments. Record review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument User's Manual MDS 3.0, dated October 2018, showed the following: -The OBRA of 1987 provided the statutory authority for federal statute and regulations that required nursing homes to conduct initial and periodic assessments for all their residents. The assessment information is used to develop, review, and revise the resident's plans of care that will be used to provide services to attain or maintain the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow standards of practice and physician orders for one resident (Resident #262) in a review of 26 sampled residents, one additional resident (Resident #14) and one discharged resident (Resident #406). The facility failed to provide and administer one resident's (Resident #262) physician ordered medications on admission to the facility, and failed to ensure one resident (Resident #406), was provided the physician ordered diet. The facility also failed to ensure staff held pressure on the lacrimal duct after administering medicated eye drops and obtain an apical (a pulse taken at the area of the apex of the heart at the point of maximum impulse) pulse prior to administering Digoxin (medication used to treat heart failure and heart rhythm problems) for one resident (Resident #14). The facility census was 117. 1. Review of Resident #406's hospital post-acute care transfer report dated 7/19/19 and sent to the facility showed the following:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility staff failed to ensure medications that could not be returned to the pharmacy were destroyed in a timely manner per facility policy. The facility census was 117. 1. Review of the facility policy Medication Destruction For Non-Controlled Medications revised [DATE] showed the following: Policy: -Discontinued medications and medications left in the facility after a resident's discharge, which do not qualify for return to the pharmacy for credit, or are donated are destroyed; Procedures: A. Unused, unwanted, discontinued, expired and non-returnable medications should be removed from their storage area and secured until destroyed. These medications may be stored in the medication room in a designated area until destroyed. Destruction should be done within 14 days; C. Medication destruction occurs only in the presence of the Director of Nursing (DON) or licensed nurse designee and a licensed nurse witness. Observation on [DATE] at 2:25 P.M., in the Long Term…

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 allow two of 26 sampled residents (Resident #4 and #12), the right to make choices about aspects of his or her life in the facility that were significant to the resident. The facility census was 117. Review of the facility policy admission Criteria dated 3/19 showed the objectives of the facility admission criteria policy included to review with the resident, and /or his/her representative, the facility's policies and procedures relating to resident rights and resident care. 1. Review of Resident #4's annual Minimum Data Set (MDS), a federally mandated assessment instrument to be completed by facility staff, dated 6/13/18, showed the following: -The resident's cognition was intact; -It was very important for him/her to choose between a tub bath, shower, bed bath, or sponge bath; -He/She required extensive assistance of one staff with personal hygiene and bathing. Review of the resident's quarterly MDS dated [DATE] showed the following:…

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 report allegations of abuse to the state agency within two hours of the incident or when an allegation was made for one resident (Resident #212) who made an allegation of sexual abuse in a review of 26 sampled residents. The facility census was 117. Review of the facility policy Abuse, last revised 12/11/17, showed Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain or mental anguish. Abuse will not be tolerated by anyone, including staff, patients, consultants, volunteers, family members or legal guardians, friends, visitor or any other individual in this center. The center administrator is responsible for assuring patient safety, including freedom from risk of abuse or neglect, holds the highest priority. Sexual Abuse: non-consensual sexual contact of any type with a patient that includes but is not limited to, sexual harassment, sexual coercion, or sexual assault. Physical Abuse includes hitting, slapping, pinching and kicking. The center will train…

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 complete comprehensive assessments timely for one sampled resident (Residents #3) in a review of 26 sampled residents and for one additional resident (Resident #5). The facility census was 117. Review of the facility policy, dated 2001 and last revised 7/17, MDS Completion and Submission Timeframes showed: Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. The Assessment Coordinator or designee is responsible for ensuring that resident assessments are submitted to CMS' QIES Assessment Submission and Processing system as soon as possible in accordance with current federal and state regulations. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual. Submission of MDS records to the QIES ASAP is electronic. A hard copy of each record submitted is maintained in the resident's clinical record for a period of fifteen months from the date submitted.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop, maintain, and update a plan of care consistent with residents' specific conditions, needs, and risks based on their comprehensive assessment for two residents (Resident #61 and #3), in a review of 26 sampled residents. The facility census was 117. Review of the facility policy, Care Plans, Comprehensive Person-Centered, dated 12/16 showed: Policy statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident' s physical, psychosocial and functional needs is developed and implemented for each resident. 1. The Interdisciplinary Team (IDT), in injunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 7. The care planning process will…

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