Fair View Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to maintain resident dignity, when staff stood over four residents (Resident #4, #22, #23 and #34) while assisting the residents to eat. The facility census was 53.1. Review of the facility's Promoting/Maintaining Resident Dignity policy, revised 09/21/25, showed all staff will speak to and treat all residents with dignity and respect, all staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights, and when interacting with a resident, pay attention to the resident as an individual.2. Review of Resident #4's Quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 02/04/26, showed staff assessed the resident as severely impaired cognition, upper extremity impairment on both sides and dependent on staff for eating.Review of the resident's care plan, dated 02/16/26, showed the plan did not direct staff on how to assist 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.

Based on observation, interview, and record review, facility staff failed to complete or post required nurse staffing information in an area readily accessible to residents and visitors. The facility census was 53.1. Review of the facility's policy titled, Nurse Staffing Posting Information Policy, reviewed 06/26/24, showed the nurse staffing sheet will be posted on a daily basis and will contain: -Facility Name; -Current date; -Facility current resident census; -The total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directedly responsible for resident care per shift: -Registered nurses (RN); -Licensed Practical Nurses (LPN)/Licensed Vocational Nurses (LVN); -Certified nurse aides (CNAs). -The facility will post the Nurses Staffing Sheet at the beginning of each shift. -The information posted will be presented in a clear and readable format and in a prominent place readily accessible to residents and visitors. 2. Observation on 04/19/26 10:30 A.M., showed facility staff did not post the nurse staff posting sheet in an area…

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 have a Registered Nurse (RN) for eight consecutive hours a day that was not the Director of Nursing (DON) with a facility census over 60 residents. The facility was 64.1. Review of the facility's Registered Nurse Policy, revised 4/30/24, showed staff are directed the DON may serve as a charge nurse only when the facility has average daily occupancy of 60 or fewer residents. 2. Review of the facility census and staffing sheets, dated 7/15/25 to 7/31/25, showed the following: -7/20/25 showed a facility census of 61, and DON worked as a charge nurse;-7/24/25 showed a facility census of 61, and DON worked as a charge nurse;-7/29/25 showed a facility census of 61, and the DON worked as a charge nurse. 3. Review of the facility census and staffing sheets, dated 8/1/25 to 8/20/25, showed the following: -8/1/25 showed a facility census of 63, and DON worked as a charge nurse;-8/2/25 showed a facility census of 62, and DON worked as a charge nurse;-8/6/25 showed a facility census of 61, and DON worked as a charge nurse;-8/7/25…

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 when staff did not complete weekly skin assessments and did not document they provided physician ordered wound treatments for three residents (Residents #1, #2, and #3) out of six sampled residents. The facility census was 61. 1. Review of the facility's Skin Assessment Policy, dated 6/26/24, showed licensed or registered nurse will conduct a full body, or head to toe, skin assessment upon admission, or re-admission and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. 2. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment tool, dated 4/5/25, showed staff assessed the resident as: -Cognitively intact; -Diagnosis of stroke, pressure ulcer of sacral region (region of the lower back) stage two (partial thickness skin loss), and chronic non pressure ulcer of the right calf with fat layer exposed; -At risk…

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 develop a comprehensive person-centered baseline care plan to meet the resident's medical, nursing, mental and psychosocial needs for one resident (Resident #1) out of two sampled residents. The facility's census was 52. 1. Review of the facility's Baseline Care Plan Policy, dated 5/18/24, showed the baseline care plan will be developed in 48 hours of a resident's admission. It should include the minimum healthcare information necessary to properly care for a resident. The admitting nurse, or supervising nurse on duty, shall gather infoamtion form the admission physical assessment, hospital transfer information, physicain orders, and discussion with teh residnt and resident representative. A supervising nurse shall verify within 48 hours that a baseline care plan has been developed. 2. Review of Resident #1's Entry Minimum Datat Set (MDS), a federally mandated assessment tool, dated 3/27/25, showed the resident admitted to the facility 3/27/25. Review of the resident's clinical admission assessment, 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 meet professional standards when staff did not obtain orders for a urinary catheter (flexible tube used to drain the bladder when someone cannot urinate on their own), catheter care, for a tracheostomy (a surgical procedure that creates an opening in the neck into the windpipe), tracheosyomy care, and did not obtain orders for a Gastrostomy (a surgical procedure creating an opening through the abdominal wall into the stomach, allowing for the insertion of a gastrostomy tube for feeding) tube, Gastrostomy tube flushes, or Gastrostomy tube care for one resident (Resident #1) out of five sampled residents. The facility census was 52. 1. Review of the facility's admission process, assignment of primary diagnosis policy, dated 12/1/22, showed a licensed or registered nurse will ensure all admission paperwork including physician orders, medications, diet orders, laboratory orders are obtained and followed. Review of the facility's Medication order policy,…

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 perform hand hygiene and/or wash hands to prevent the spread of infection during medication pass for five residents (Residents #3, #20, #29, #41, and #48) of six sampled residents, and during perineal care for two residents (Resident #22 and #38) of two sampled residents. Facility staff failed to follow infection control protocols for cleaning/disinfecting the glucometer (a device used to measure blood sugar levels) when staff tested four residents (Resident #23, #26, #31, and #58) of four sampled resident blood sugar levels. Facility failed to ensure the two-step purified protein derivative ( (PPD) skin test for Tuberculosis (TB) ) was completed in accordance with their policy and on file for six employees (Registered Nurse (RN) E, Nurse aide (NA) D, housekeeping aide I, Maintenance J, Certified nurse aide (CNA) K, and Licensed Practical Nurse (LPN) S) out of ten employee files reviewed. Facility staff failed to have and maintain…

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 check the Employee Disqualification List (EDL) (a list of individuals who have been determined to have abused or neglected a resident or misappropriated funds or property belonging to a resident), criminal background check (CBC), and Family Care Safety Registry (FCSR) prior to hire in accordance with their facility policy for nine (Registered Nurse (RN) E, Nurse Aide (NA) D, Certified Medication Technician (CMT) F, Dietary Aide G, laundry aide H, housekeeping aide I, maintenance J, Certified Nurse Aide (CNA) K, and CNA L) out of ten sampled employees. The facility census was 53. 1. Review of the Facility's Screening- Applicant, Employee, Volunteer and Vendor (Missouri) policy, Revised May 2024, showed: -HR staff will conduct the following screens on potential employees prior to hire; -Criminal history- Using the request for Criminal Record Check, a criminal background check should be done through Missouri Highway Patrol's Missouri Automated Criminal History Site; -FCSR; -EDL list. 2. Review of RN E's personnel record…

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 acceptable standards of practice when staff failed to complete neurological assessments (evaluation completed by staff for early detection of nervous system damage following head trauma) for two of four sampled residents (Resident #3, and #18). Ensure pressure relieving devices were in place for two out of three sampled residents (Resident #20, and #22). Staff failed to provide wound care treatment per physician orders for one out of one sampled resident (Resident #40). The census was 53. 1. Review of the facility's Head Injury policy, revised 05/18/2024, showed staff are directed as follows: -Assess resident following a known, suspected or verbalized head injury. The assessment shall include, at a minimum: a. Vital signs. b. General condition and appearance. c. Neurological evaluation for changes in: Physical functioning, Behavior, Cognition, Level of consciousness, Dizziness, Nausea, Irritability, and Slurred speech or slow 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, facility staff failed to provide adequate baths/showers to maintain proper hygiene for four residents (Resident #15, #26, #37, #38) out of seven sampled residents, and one additionally sampled resident (Resident # 35), who required assistance from staff to complete their Activities of Daily Living (ADLs) (bathing, showering, dressing, transfers, toileting, etc.). The facility census was 53. 1. Review of the facility's Resident Showers Policy, revised 06/26/24, showed the purpose is to assist residents with bathing to maintain proper hygiene, and directed staff as follows: -Resident will be provided showers as per request or as per facility schedule protocols and based upon resident safety; -Partial baths may be given between regular shower schedules as per facility policy; -Assist the resident with showering as needed. 2. Review of Resident #15's annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 06/04/24, showed staff assessed the…

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

Based on interview and record review, facility staff failed to provide an ongoing activity program to meet the needs, interests, and physical, mental, and psychosocial well-being for four (Resident #23, #44, #48, and #58) out of 14 sampled residents on weekends. The facility staff failed to post an activities calendar for residents to view. The facility census was 53. 1. Review of the facility's policy titled, Activities, dated 07/23, showed the facility will provide an ongoing program of activities designed to meet, in accordance with comprehensive assessment, their interests and their physical, mental and psychosocial well-being. Review showed staff were directed to: -Activities will be designed with the intent to promote and enhance the emotion health, self-esteem, pleasure, comfort, education, creativity, success, and independence for all residents, based on interview and assessing the residents like and dislikes; -The activities calendar will be posted on each unit and will include activities that are appropriate for the general therapeutic milieu population that meets the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to maintain a medication error rate of less than 5%. Out of 29 opportunities observed, six errors occurred, resulting in a 20.69% error rate, which effected four residents (Resident #23, #26, #31, #58) out of ten sampled residents. The facility census was 53. 1. Review of the Facility's Medication Errors policy, dated [DATE], showed the facility shall ensure medications will be administered as follows: -According to physician orders; -In accordance with accepted standards and principles which apply to professionals providing services; -The facility must ensure that it is free of medications error rates of 5% or greater as well as significant medication error events; -The facility will consider factors indicating error in medication administration, including, but not limited to, the following: -Medication administered not in accordance with prescriber's order. Examples include but not limited to incorrect dose, route of administration,…

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 written information to the resident and/or the resident's representative of the bed hold policy at the time of transfer to the hospital for three (Resident #22, #36, and #47) out of three sampled residents. The facility's census was 53. 1. Review of the facility policies showed staff did not provide a policy for bed hold notification. 2. Review of Resident #22's medical record showed the resident discharged from the facility on 07/10/24 and readmitted to the facility on [DATE]. The record did not contain written documentation staff notified the resident or the resident's responsible party of the facility's bed-hold policy. 3. Review of Resident #36's medical record showed the resident: -discharged on 08/08/24 and readmitted to the facility on [DATE]; -discharged on 06/22/24 and readmitted to the facility on [DATE]; -discharged on 06/03/24 and readmitted to the facility on [DATE]; -Did not contain written documentation staff notified the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, facility staff failed to ensure Level I Pre-admission Screening (used to evaluate for the presence of psychiatric conditions to determine if a Pre-admission Screening and Resident Review (PASRR) level II screen is required) were completed for two residents (Resident #8, and #26) out of two sampled residents. The facility census was 53. 1. Review of the facility's policies showed staff did not provide a policy for PASRR. 2. Review of the Central Office Medical Review Unit (COMRU) website, https:// health.mo.gov/seniors/nursinghomes/pasrr.php, dated 09/04/24, showed the PASRR is a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis who apply or reside in Medicaid Certified beds in a nursing facility regardless of the source of payment. The screening assures appropriate placement of persons known or suspected of having a mental impairment(s) and also the individual needs of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to ensure call lights were within reach for three residents (Resident #10, #27, and #40) out of 14 sampled residents. The facility census was 53. 1. Review of the facility's policy titled, Call Light Accessibility and Timely Response, dated 4/30/24, showed all staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light. All residents will be evaluated on how to call for help by using the resident call system. Staff will ensure the call light is within reach of resident and secured, as needed. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room. The call system should be accessible to a resident lying on the floor. 2. Review of Resident #10 Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 05/28/24, showed staff assessed the resident as follows:…

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 ensure ten Nurse Aides (NA) (NA A, NA B, NA C, NA D, NA E, NA F, NA G, NA H, NA I, and NA J) completed the nurse aide training program within four months of their employment in the facility. The facility census was 50. 1. Review of the facility policy titled, Nurse Aide Qualifications and Training Requirements, revised August 2022, showed the following: -Policy Statement: Nurse aides must undergo a state-approved training program; -Nurse Aide is any individual providing nursing or nursing-related services to residents in a facility. This term may also include an individual who provides these services through an agency or under a contract with the facility, but is not a licensed health professional, a registered dietitian, or someone who volunteers to provide such services without pay; -The facility will not employ any individual as a nurse aide for more than four months full-time, temporary, per diem, or otherwise, unless that individual is competent to provide designated nursing care and nursing related services; 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 staff failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. The facility census was 50. 1. Review of the facility's Nursing Services Policy, revised 05/01/23, showed the facility will ensure that a registered nurse is on duty to provide RN services at least 8 consecutive hours, 7 days a week. 2. Review of RN A's payroll detail report, dated 9/24/23 - 10/8/23 showed the following hours worked: -On 10/05/23 RN A worked 12:00 A.M. and clocked out at 7:00 A.M.; -On 10/07/23 RN A did not work any hours; -On 10/08/23 RN A did not work any hours. Review of the Nurses schedule, dated 10/01/23-10/31/23, showed RN A was scheduled as follows: -On 10/05/23 RN A was scheduled to work 6:00 P.M. to 6:00 A.M.; -On 10/07/23 RN A was scheduled off; -On 10/08/23 RN A was scheduled off. Review of the payroll detail report, dated 9/24/23-10/8/23, did not show another RN clocked hours for the dates of 10/07/23 and 10/08/23. During an interview on 10/12/23 at 1:15 P.M., the Director 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 perform hand hygiene as often as necessary using approved techniques to prevent cross-contamination. The facility census was 47. 1. Review of the facility's Handwashing/Hand Hygiene policy dated August 2019, showed the policy directed: -All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors; -Wash hands with soap and water when hands are visibly soiled; -Use an alcohol-based hand rub containing at least 62 percent alcohol or, alternatively, soap and water after handling contaminated equipment; after contact with objects in the immediate vicinity of the resident; before and after glove use; and before and after eating or handling food; -Hand hygiene is the final step after removing and disposing of personal protective equipment; -To wash hands: *Wet hands first with water, then apply an amount of product recommended by the manufacturer to hands; *Rub hands together vigorously for at least 15 seconds, covering…

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 review and revise the plan of care for one resident (Resident #5) after the completion of Quarterly Minimum Data Set (MDS), a federally mandated assessment tool. Additionally, staff failed to review and revise the plan of care with changes in the resident's needs for six residents (Resident #3, #4, #10, #23, #24 and #44). The facility census was 47. 1. Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated March 2022, showed staff were directed to do the following: -The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment; -Reflects currently recognized standards of practice for problem areas and conditions; -Assessments of resident's are ongoing and care plans are revised as information about the residents and the resident's condition change; -The Interdisciplinary Team (IDT) reviews and updates the care plan when there has…

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 provide an ongoing program of activities designed to meet the residents' interest during the weekends. The facility census was 47. 1. Review of the facility's policy titled, Activity Programs Staffing, revised June, 2018, showed staff were directed to do the following: -Our activity programs are staffed with personnel who have appropriate training and experience to meet the needs and interests of each resident; -Sufficient activity personnel are on duty to meet the needs of the residents and functions of the activity programs; -When a qualified professional is not on premises, the day-to-day functions of the activity programs are under the supervision of an assistant activity director/coordinator or another facility staff member as designated by administration; -Sufficient activity personnel are on duty to meet the needs of the residents and the functions of the activity programs. Review of the facility's policy titled, Activity Programs, revised June 2018, showed staff were directed to do 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 three residents (Resident #5) had an appropriate indication for the use of antipsychotic medications. Additionally, staff failed to provide a 14-day stop date for as needed (PRN) antianxiety medication, for four residents (Residents #3, #14, #44, and #46). The facility census was 47. 1. Review of facility's policy Psychotropic Medication Use, dated July 2022, showed staff were directed to do the following: -Resident will not receive medications that are not clinically indicated to treat a specific condition; -Psychotropic medication management, includes indication for use. -PRN orders for psychotropic medications are limited to 14 days; -For psychotropic medications that are not antipsychotics, if the prescriber believes it is appropriate to extend the PRN beyond 14 days, physician will document the rationale for extending the use and include duration for the PRN order; -For psychotropic medications that are antipsychotics, the…

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

Based on observation, interview, and record review, facility staff failed to maintain a correct count of controlled medications for three residents (Resident #14, #42 and #3). The facility census was 47. 1. Review of facility's policy Controlled Substances, dated April 2019, showed staff were directed to do the following: -The nurse administering a controlled medication, is responsible for documenting the quantity of the medication remaining; -Controlled medications are counted at the end of each shift; -The nurse coming on duty and the nurse going off duty determine the count together; -Any discrepancies in the controlled substance count are documented and reported to the Director of Nursing (DON) immediately. 2. Review of Resident #14's Controlled medication log, dated 05/16/2023, showed staff documented the resident had 13.5 milliliters (ml) of Morphine (narcotic pain medication) available. Further review showed Licensed Practical Nurse (LPN) E signed the log as accurate. Observation on 05/16/23 at 10:39 A.M., showed the resident's Morphine bottle contained 19 ml of the liquid…

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 observation, interview and record review, facility staff failed to ensure one resident (Resident #17) with contractures (changes to joint tissues that can lead to tightening, and immobility) received appropriate treatment and services to prevent further decrease in range of motion (ROM) (motion of a joint). The facility census was 47. 1. Review of the facility's policy titled, Resident Mobility and Range of Motion, revised July, 2017, showed staff were directed to do the following: -Residents with limited ROM will receive treatment and services to increase and/or prevent a further decrease in ROM; -Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable; -Further review showed the policy did not contain direction for staff in regard to following physician orders for the treatment of contractures. -Staff to include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion in the care plan. 2.…

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

Based on observations, interviews, and record review, facility staff failed to obtain orders for dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly), or have a system in place for ongoing communication with the dialysis clinic for one resident (Resident #10) who receives dialysis. Additionally, facility staff failed to monitor or assess the resident before and after dialysis treatments. The facility census was 47. 1. Review of the facility's policy titled, Hemodialysis Access Care, dated September 2010, showed staff were directed to do the following: -The dressing change is done in the dialysis center post-treatment; -If dressing becomes wet, dirty, or not intact, the dressing shall be changed by a licensed nurse trained in this procedure; -Mild bleeding from site (post-dialysis) can be expected. Apply pressure to insertion site and contact dialysis center for instructions; -The general medical nurse should document in the resident's medical record every shift as follows: -Location of catheter; -Condition of dressing…

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.