Seville Care Center

Based on record review and interviews, the facility staff failed to ensure one resident (Resident #1) out of three residents were allowed to make choices about aspects of their lives when staff did not allow the resident who is his/her own responsible party and assessed to smoke a cigarette independently as a consequence for his/her behavior. The facility census was 44. 1. Review of the facility's Resident Rights policy, undated, showed residents have the right to a dignified existence and self-determination. Review of the facility's smoking policy, dated 01/08/23, showed: -Resident's will be assessed at the time of admission and reassessed at a minimum quarterly or with a significant change to determine the level of assistance and supervision required to ensure resident safety; -Resident's who are determined by the care plan team to be able to smoke without supervision may smoke at-will in the designated smoking area only; -Any and all residents that are not deemed capable of smoking unsupervised, will be given the opportunity to smoke with supervision at the facility's designated…

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 record review, facility staff failed to notify the physician in a timely manner for one resident (Resident #1) who stated he/she felt like harming himself/herself. The facility census was 44. 1. Review of the facility's policy titled, Behavioral Assessment, Intervention and Monitoring, dated February 2023, showed staff were directed to do the following: -Any resident with a behavior that has been identified would present a potential danger to either himself/herself or other residents will be placed on increased visual monitoring, unless other immediate interventions are needed; -The charge nurse will notify the attending physician and family of the behavior. 2. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/22/23, showed staff assessed the resident as follows: -Cognitively intact; -Did not exhibit signs of feeling down, depressed or hopeless or thoughts he/she would be better of dead, or of hurting themselves in some way; -Diagnosis of depression (a mood disorder that causes a persistent feeling of…

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

Based on observation, interview and record review, the facility staff failed to serve food in accordance with the nutritionally calculated menus and standardized recipes. The facility census was 44. 1. Observation on 11/13/23 at 12:15 P.M., showed [NAME] N served residents the noon meal per the Week one, Day two preplanned menu. Observation also showed -regular menu listed baked mostaccioli serving size as a six ounce spoodle, staff served the entree using a four ounce spoodle -regular menu listed apple crisp serving size as a #6 dip (5.33 ounces), staff served the fruit using a four ounce spoodle -pureed menu listed baked mostaccioli serving size as a #6 dip, staff served the pureed entree using a #8 dip (four ounces) -pureed menu listed italian vegetables serving size as a #12 dip (2.67 ounces), staff served the pureed vegetables using a #8 dip (four ounces) -pureed menu listed apple crisp serving size as a #6 dip, staff served the pureed entree using a #16 dip (two ounces) -pureed menu listed bread serving size as a #20 dip (1.6 ounces), staff served the pureed entree using a #8…

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, facility staff failed to maintain kitchen exhaust fans, lighting devices and ceiling surfaces in a clean sanitary manner to prevent the potential for cross-contamination. The facility census was 44. 1. Observation of the kitchen on 11/13/23 at 11:05 A.M., showed: -The ceiling above the three part sink had a large unfinished, repaired area. Observation showed the gypsum wallboard was unpainted and the joints were not taped or sealed, leaving gaps in the ceiling. Observation also showed the patched area was not flush and large areas hung below the ceiling level, exposing gypsum material; -Two ceiling exhaust fans had large accumulations of dust and grease; Six fluorescent tube light fixtures had missing covers, exposing twelve light bulbs; During an interview on 11/14/23 at 11:05 A.M., the dietary manager said the dietician told him/her about dirty kitchen exhaust fans and broken light covers in the resident dining room. The dietary manager said the dietician did not mention the missing light covers in the kitchen. During an interview…

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 create an environment respectful of the rights of each resident to make choices about significant aspects of their lives for five residents (Residents #21, #24, #25, #34 and #43), when facility staff did not honor residents dietary preferences. The facility census was 44. 1. Review of the facility's policy titled, Resident's Rights, dated Month 2009, showed staff employees shall treat all residents with kindness, respect, and dignity. Residents are entitled to exercise their rights and privileges to the fullest extent possible. Review of the facility's policy titled, Resident Food Preferences, dated December 2008, showed the Dietician will visit residents periodically to determine if revisions are needed regarding food preferences. The nursing staff will inform the kitchen about resident requests. The Food Services Department will offer a limited number of food substitutes for individuals who do not want to eat the primary meal. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, facility staff failed to provide a comfortable and homelike environment for residents, when staff failed to maintain walls, floors, doors, door frames, lighting devices, and an effective pest control program. The facility census was 44. 1. Review of the policies provided by the facility did not contain a policy for environmental concerns. 2. Observations on 11/13/23 and 11/14/23 during the Life Safety Code tour showed: -a broken hall light cover outside resident room [ROOM NUMBER]; -a large accumulation of dead insects in the hall light between resident rooms [ROOM NUMBERS]; -a large brown stain on the ceiling outside resident room [ROOM NUMBER]; -a broken light cover outside resident room [ROOM NUMBER]; -a missing hall light cover between resident rooms [ROOM NUMBERS]; -a cracked hall light cover outside resident room [ROOM NUMBER]; -a large unfinished ceiling patch over the North nurse station; -a large accumulation of dead insects in the hall light between resident rooms…

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 and interview, facility staff failed to complete a baseline care plan within 48 hours of admission for four residents (Resident #7, #30, #41, and #46). The facility census was 44. 1. Review of the policies provided by the facility did not contain a policy for baseline care plans. 2. Review of Resident #7's medical record showed staff documented the resident was admitted to the facility on [DATE]. Additional review showed the record did not contain a baseline care plan. 3. Review of Resident #30's medical record showed staff documented the resident was admitted to the facility on [DATE]. Additional review showed the record did not contain a baseline care plan. 4. Review of Resident #41's medical record showed staff documented the resident was admitted to the facility on [DATE]. Additional review showed the record did not contain a baseline care plan. 5. Review of Resident #46's medical record showed staff documented the resident was admitted to the facility on [DATE]. Additional review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility staff failed to ensure eight residents (Residents #5, #7, #11, #23, #32, #34, #36 and #37), who were unable to complete their own activities of daily living (ADLs), received the necessary care and services to maintain good personal hygiene. The facility census was 44. 1. Review of the policies provided by the facility did not contain a policy for ADLs. 2. Review of Resident #5's Significant Change Minimum Data Set (MDS), a federally mandated assessment tool, dated 08/31/23, showed staff assessed the resident as follows: -Severe cognitive impairment; -Did not reject care; -Dependent on staff for toileting, bathing, dressing, bed mobility and transfers; -Always incontinent of bowel and bladder; -Diagnosis of dementia (progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). Review of resident's care plan, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, facility staff failed to provide a 14-day stop date for as needed (PRN) psychotropic medications (any drug that affects behavior, mood, thoughts or perceptions), for three residents (Residents #6, #30, and #41). The facility census was 44. 1. Review of the policies provided by the facility did not contain a policy for psychotropic medications. 2. Review of Resident #6's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 9/18/23, showed staff assessed the resident as: -Severe cognitive impairment; -Diagnoses of Alzheimer's Disease (progressive disease that destroys memory and other important mental functions), Dementia (progressive and persistent of intellectual functioning, with impairment in memory and abstract thinking), Anxiety Disorder (feeling of worry, anxiety, or fear strong enough to interfere with daily function), Depression and Psychotic Disorder (disconnection from reality). Review of the resident's Physician Order Sheet (POS), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to provide a safe mechanical lift transfer for one resident (Resident #8) and failed to keep residents safe while smoking by not implementing smoking interventions and utilizing smoking assistive devices for two residents (Resident #34 and #36). The facility census was 44. 1. Review of the facility's policy titled, Lifting Machine, Using a Portable, dated 10/10, showed staff were directed to do the following: -To transfer a resident from a bed to a chair, you should position the resident comfortably in the chair, grasp the top of the sling with one hand and pull back on the sling while lowering the resident into the chair. -Review showed it did not contain direction for staff to guide the resident while using the machine or the positioning of the legs of the machine. 2. Review of Resident #8's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 06/18/23, showed staff assessed the resident as: -Did not contain…

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 and implement complete policies and procedures for the inspection, testing and maintenance of the facility water systems to inhibit growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD). Additionally, facility staff failed to remove soiled gloves and/or properly wash hands during incontinence care for two residents (Resident #8 and #25) to prevent the spread of bacteria and other infection causing contaminants. The facility census was 44. 1. Review of the Centers for Medicare and Medicaid Services (CMS) Quality, Safety and Oversight memo (QSO-17-30- Hospitals/CAHs/NHs), revised 7/06/18 showed: In manmade water systems, Legionella can grow and spread to susceptible hosts, such as persons who are at least [AGE] years old, smokers, and those with underlying medical conditions such as chronic lung disease or immunosuppression. Legionella can grow in parts of building water systems that are…

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 conduct inspections of bed rails as part of a regular maintenance program for two residents (Resident #8 and #20) to identify areas of possible entrapment. The facility census was 44. 1. Review of the United States Food and Drug Administration (FDA) document entitled, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated March 10, 2006, showed 413 people died as a result of entrapment events in the United States. Further review showed those among the most vulnerable for these entrapment type events are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. Review of the FDA document entitled, Practice Hospital Bed Safety, dated February 2013 identifies seven different potential, zones of entrapment. This guidance characterizes the head, neck, and chest as key body parts that are at risk of entrapment. Review of the FDA document entitled,…

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 and interviews, facility staff failed to properly maintain the temperature of hot food at or above 120 Degrees Fahrenheit (°F) and cold foods at or below 41° F for for 9 residents (Resident #5, #16,#17,#25, #28, #29, #31, #35, and #494) at the time of meal service and failed to implement a system of monitoring food temperatures at the time of service. Failure to maintain foods at the proper temperature has the potential to affect all residents who received room trays. Further, staff failed to serve palatable food to residents. The facility census was 42. 1. Review of the facility's Meal Service Temperatures policy dated, revised January 2017, showed staff were directed as follows: -Meal temperatures shall be monitored by the dietary manager and the cooks on a daily basis. Hot food shall be cooked or heated to a temperature above 165 degrees. Cold food shall be chilled to a temperature below 40 degrees. 2. Observation on 9/15/22 at 8:36 A.M., showed staff delivered a covered hall tray to Resident #5's room. The tray contained fried eggs 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.

Based on observation, interview and record review, the facility staff failed to perform hand hygiene as often as necessary to prevent cross-contamination. Facility staff failed to allow sanitized dishes to air dry prior to stacking in storage to prevent the growth of food-borne pathogens. Facility staff failed to appropriately wash and sanitize manually washed kitchenware to prevent cross-contamination. Facility staff failed ensure kitchen waste containers were covered when not in actual use to deter the attraction of pests and rodents. Facility staff failed to prepare pureed food items in accordance with standardized recipes to ensure pureed foods served to four residents (Residents #11, #12 #15 and #34) were reheated to an internal temperature of 165 degrees Fahrenheit (dF) or greater prior to service to prevent the growth of food-borne pathogens and food-borne illness. Facility staff also failed to thaw meat in a manner to prevent the growth of food-borne pathogens and food-borne illness. The facility census was 42. 1. Review of the facility's handwashing policy dated 2017,…

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 and interview, the facility staff failed to refund resident funds within 30 days of discharge for six residents (Resident # 286, #287, #288, #289, #290 and #291). The facility census was 42. Review of the facility policies showed they did not have a policy for resident refunds after discharge. 1. Review of the facility's aging report, dated 9/15/22, showed the following residents had money in the facility's operating account: -Resident #286 was discharged on 5/21/20: with a balance of $763.35; -Resident #287 was discharged on 2/14/22: with a balance of $1681.80; -Resident #288 was discharged on 2/1/21: with a balance of $152.67; -Resident #289 was discharged on 3/5/21: with a balance of $152.55; -Resident #290 was discharge on [DATE]: with a balance of $976.38; -Resident #291 was discharged on 6/3/22: with a balance of $1,410.66. 2. During an interview on 9/16/22 at 11:30 A.M., the Business Office Manger (BOM) said he/she reviews the accounts receivable report with corporate staff every…

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

Based on interview and record review, facility staff failed to purchase a surety bond in an amount sufficient to assure security of all resident funds the facility holds. The facility census was 42. 1. Review of the resident's trust fund account for September 2021 through August 2022, showed an average monthly balance of $34,001.33, which requires a surety bond of $45,000.00. Further review showed the current ledger amount was $32,430.90. Review of the Department of Health and Senior Services (DHSS) database, showed the facility has an approved non-cancelable Escrow Agreement Account in the amount of $40,000.00. During an interview on 9/16/22 at 10:30 A.M., the Business Office Manager (BOM) said the administrator was responsible to ensure the bond amount was sufficient. He/She said after the previous administrator left and the new corporation took over, After change in staff, I guess no one really knew about it, I just figured it out when I was getting it together for you. During an interview on 9/16/22 at 11:00 A.M., the Administrator said it is the business office manager'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 interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan to include the triggered care areas for four residents (Resident #14, #17, #24 and #30). The facility census was 42. 1. Review of the facility's Care Planning- Interdisciplinary Team Policy, dated 2/2021, showed staff is directed to the following: -Every resident will be assessed using the Minimum Data Set (MDS) according to the guidelines set forth in the Resident Assessment Instrument (RAI) manual; -To use this assessment data to develop a comprehensive Plan of Care (POC) for each resident that will assist a resident in achieving and maintaining the highest practical level of mental functioning, physical functioning, and wellbeing as possible; -Upon completion of comprehensive assessments (as defined by the RAI Manual), Care Area Assessment (CAA)s will be triggered to flag areas of concern that may need to be addressed in the POC for the resident. Each triggered CAA will be reviewed by…

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 staff failed to ensure the comprehensive care plans were updated for three residents (Resident #3, #21, and #489). The facility census was 42. 1. Review of the facility's Care Planning- Interdisciplinary Team Policy, dated 2/2021, showed staff is directed to the following: -Every resident will be assessed using the Minimum Data Set (MDS), a federally mandated assessment tool, according to the guidelines set forth in the Resident Assessment Instrument (RAI) manual; Use this assessment data to develop a comprehensive Plan of Care (POC) for each resident that will assist a resident in achieving and maintaining the highest practicable level of mental functioning, physical functioning, and well-being as possible; -The clinical record is also utilized to gather data including (but not limited to) nursing notes, medication/treatment records, lab results, physician notes, and demographic information; -The policy does not indicate the time frame POCs should be reviewed 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, facility staff failed to meet professional standards of care delivery when they failed to date and time Fentanyl patches for two residents (Residents #7 and #30), obtain a physician's order for the delivery of Continuous Positive Airway Pressure / Bilevel Positive Airway Pressure (CPAP / BiPAP, a device that helps with breathing) for two residents (Resident #14 and #35), ensure correct delivery of respiratory medications for two residents (Residents #3 and #490), address multiple treatment refusals or inability to perform treatments for one resident (Resident #490) and follow physician's orders for two residents (Residents #3, and #10). The facility census was 42. 1. Review of the facility policies showed staff did not provide a policy for dating and timing of Fentanyl patches. Review of Missouri Certified Medication Technician Student Manual, 2008 Revision showed the procedure PREPARE, ADMINISTER, REPORT, AND RECORD TRANSDERMAL PATCHES included Label…

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

Based on interview and record review, facility staff failed to implement an Antibiotic Stewardship Program with antibiotic use protocols and a system to monitor antibiotic use. The facility census was 42. 1. Review of the facility's Infection Prevention and Control Program, dated 2019 showed: -Develops and implements an ongoing infection prevention and control program (IPCP) to prevent, recognize and control the onset and spread of infection to the extent possible and reviews and updates the IPCP annually, based upon the facility assessment and as necessary. This would include revision of the IPCP as national standards change; -The Infection Preventionist (IP) will oversee the facility Antibiotic Stewardship Program; --Review of the use of antibiotics (including comparing prescribed antibiotics with available susceptibility reports) is a vital aspect of the infection prevention and control program; --Involve the consultant pharmacist with the oversight by identifying antibiotics prescribed for resistant organisms; --Track antibiotic use monthly and complete an antibiogram ( a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility staff failed to ensure medication regimens were free from unnecessary medications when staff failed to obtain an appropriate diagnosis for the use of psychotropic medications (a chemical substance that changes brain function and results in alterations in perception, mood, consciousness or behavior) for two residents (Residents #21 and #35). The facility census was 42. 1. Review of American Geriatrics Society (AGS), updated 2019, AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults showed: - Avoid antipsychotics for behavioral problems of dementia or delirium unless nonpharmacological options (e.g., behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others; -Strength of recommendation - Strong. Review of the prescribing information for Zyprexa/Olanzapine (antipsychotic) showed: -Zyprexa is an atypical antipsychotic indicated for schizophrenia and Bipolar I…

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 store and label medication in a safe and effective manor in one of two medication storage rooms and in one of two medication storage carts. The facility census was 42. 1. Review of the facility's Medication Storage Policy, dated [DATE], showed expired medication will be removed by the facility and destroyed or sent back to the pharmacy. Disposal of any medications prior to the expiration date will be required if contamination or decomposition is apparent. Observation on [DATE] at 10:15 A.M., showed the 100 hall medication storage room contained; - 6 100 tablet bottles of folic acid 400 mg with an expiration date of 8/22; - 2 100 tablet bottles of calcium 250 mg + D3 with an expiration date of 6/22; - 2 insta-Glucose 2 mg tubes with an expiration date of 6/22. Observation on [DATE] at 10:35 A.M., showed the 100 hall medication storage cart contained; - 1 loose tablet labeled Senna PSD 22; - 1 loose tablet labeled Ibu 44 291 brown; - 1…

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 use proper hand hygiene and provide perineal care in a manner to reduce the risk of infection for two residents (Residents #7, and #34). Additionally, staff failed to provide wound care in a manner to reduce the risk of infection for two residents, (Residents #31, and #494). The facility census was 42. 1. Review of the facility's Infection Prevention and Control Manual, dated 2019, showed the hand hygiene procedure referred to the CDC website for further information on appropriate hand hygiene. Review of the CDC website showed: -Multiple opportunities for hand hygiene may occur during a single care episode. Following are the clinical indications for hand hygiene: --Before moving from work on a soiled body site to a clean body site on the same patient; --Immediately after glove removal. 2. Review of Resident #7's Annual Minimum Data Set (MDS), a federally mandated resident assessment tool, dated 6/21/22 showed staff assessed the resident…

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