Four Seasons Living Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to provide a comfortable and homelike environment for residents, when staff failed to clean and maintain resident room and common area walls, doors, windows, floors, toilets, air conditioning (A/C) units, bathroom vents, and furniture. Facility staff failed to ensure residents had access to clean clothes and linens in a timely manner and failed to assist residents with laundry as needed. The facility census was 231 with a capacity of 239. 1.Review of the facility policy titled Safe and Homelike Environment Policy, dated 06/5/24, showed the facility will provide a safe, clean, comfortable and homelike environment. The facility will create and maintain, to the extent possible, a homelike environment that deemphasizes the institutional character of the setting. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary and comfortable environment. The facility will provide and maintain bed and bath linens 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 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 and failed to send a copy of the notice of transfer and/or discharge for eight residents (Resident #4, #7, #9, #12, #91, #93, #100, and #150) out of eight sampled to the representative of the Office of the State Long-Term Care (LTC) Ombudsman. The facility census was 231. 1. Review of the facility's policy titled Bed Hold, revised 06/12/2025, showed: -Before a resident is transferred or discharged , the facility must: -Notify the resident and the resident representative the reason for the transfer or discharge in writing in a manner they understand; --Notify a representative of the Office of the State Long-Term care Ombudsman; --A copy of the discharge/transfer notice shall be sent to the Ombudsman at least 30 days in advance of a discharge or as soon as possible; --In the case of an emergency or immediate…

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 ten residents (Resident #12, #19, #57, #58, #76, #82, #91, #117, #185, and #211) out of 45 sampled residents with changes in the resident's needs. The facility census was 231.1. Review of the facility policy titled Comprehensive Care Plans, dated 10/31/24, showed it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident's rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan will describe resident specific interventions that reflect the resident's needs and preferences and will be prepared by an interdisciplinary team. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly…

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 care, to maintain personal hygiene, grooming, bathing and nail care for four residents (Residents #211, #233, #149, and #77) out of a sample of 45 residents. The facility census was 231.Review of the facility's policy titled Activities of Daily Living (ADLs), dated 05/18/24, showed a resident who is unable to carry out ADLs will receive the necessary services, to maintain good nutrition, grooming and personal hygiene. The facility will provide a maintenance and restorative program to assist the resident in achieving and maintaining the highest practicable outcome based on comprehensive assessment. The facility will maintain individual objectives of the care plan and periodic review and evaluation. 1. Review of Resident #233's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 09/5/25, showed staff assessed the resident as:-Severe cognitive impairment;-Rejection of care not exhibited;-Required moderate…

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 nine Nurse Aides (NA) (NA D, NA I, NA P, NA V, NA W, NA X, NA Y, NA Z, and NA AA) out of nineteen sampled staff, completed the nurse aide training program within four months of his/her employment in the facility. The facility census was 233.1. Review of the facility's policies showed the facility did not provide a policy for NA qualifications.2. Review of NA D's CNA report showed a hire date of 04/28/25. Review showed the file did not contain documentation the NA completed a nurse aide training program.3. Review of NA I's CNA report showed a hire date of 08/26/24. Review showed the file did not contain documentation the NA completed a nurse aide training program.4. Review of NA P's CNA report showed a hire date of 07/15/25. Review showed the file did not contain documentation the NA completed a nurse aide training program.5. Review of NA V's CNA report showed a hire date of 06/16/25. Review showed the file did not contain documentation the NA completed a nurse aide training program.6. Review of NA W's CNA report…

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 train their staff on how to adequately care for residents behavioral health needs and two residents, with behavioral health needs, were involved in a resident to resident altercation (Resident #22 and #44) and failed to educate staff on resident specific behaviors and interventions for seven residents (Resident #170, #19, #27, #116, #129, #163, and #211) of 35 sampled residents on two units, the women's behavioral health unit and Tiger Lane. The facility census was 231. 1. Review of the facility's Behavioral Health Services Policy, revised 10/31/24, showed it is the policy of the facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use…

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 document the administration of controlled substance medications in the facility's Control Drug Record book (used to reconcile narcotic medications) at time of administration for three residents (Resident #166, #189 and #116) out of 45 sampled residents. The facility census was 231. 1.Review of the facility's Controlled Substance Administration and Accountability Policy, dated 05/14/24, showed the following:-It is the policy of this facility to promote safe, high quality patient care, complaint with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure;-All controlled substances obtained from a non-automated medication cart or cabinet are recorded on the designated usage form. Written documentation must be clearly legible with all applicable information provided;-The Controlled Drug Record (or other…

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 ensure drugs used in the facility were labeled in accordance with currently accepted professional principles when unpackaged, loose medications were found in five of seven medication carts observed. The facility census was 231.1.Review of the facility's, Medication Storage Policy, dated 05/18/24, showed the policy did not provide guidance regarding loose medications in the medication carts. Observation on 12/01/2025 at 9:55 A.M., showed the 200 hall medical unit medication cart with one crushed pill and one blue and yellow capsule loose in the cart. Observation on 12/01/2025 at 10:19 A.M., showed the 100 hall medical unit medication cart with two white tablets, one pink tablet, and one white tablet in the narcotic box all loose in the cart. Observation on 12/01/2025 at 10:37 A.M., showed the woman's behavior unit medication cart with three white tablets and one yellow tablet loose in the cart. Observation on 12/01/2025 at 10:50 A.M., showed the men's behavior unit medication cart with one purple and pink…

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 ensure prepared food items were served at a safe and appetizing temperature to residents who ate in the Main Street and 400 hall dining rooms. Facility staff failed to ensure the internal temperature of hot food held in the steam table measured at least 140 degrees Fahrenheit (dF) and failed to ensure the internal temperature of hot food measured at least 120 dF upon service to the residents. The facility census was 231. 1. Review of the facility's policy titled Dietary Food Preparation, revised 07/05/23, showed:-Foods will be served at the proper temperature to ensure food safety;-Staff are to check the internal temperature of foods to be served with a probe-type thermometer at the beginning of the service and during service;-The acceptable serving temperature for hot food is 135 dF, but preferably 160-175 dF;-If the food temperatures do not meet acceptable serving temperatures, reheat the product to the proper temperature;-If temperatures are not at acceptable levels and cannot be corrected in time for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to notify one resident's (Resident #1's) responsible party after the resident had a change in condition. Facility staff failed to notify one resident's (Resident #3's) physician out of two sampled residents when staff did not administer the resident's medications. The facility census 231.1. Review of the facility's Notification of Change policy, dated 05/14/24, showed the purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring Notification include accidents, resulting in injury or potential to require physician intervention.2. Review of Resident #1'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, facility staff failed to review and revise the plan of care with changes in the resident's needs for two residents (Resident #1 and #2) out of three sampled residents. Facility staff also failed to update the plan of care with behavioral interventions for one resident (Resident #8) out of one sampled resident. The facility census was 231. 1. Review of the facility's MDS 3.0, Care Assessment Summary and Individual Care Plans policy, dated 11/06/23, showed staff are directed as follows:-The Plan of Care should address improvements where possible and maintenance and prevention of avoidable declines and all Care Area Triggers;-There are twenty (20) areas that can become triggered areas for concern and must be addressed with individualized interventions on the plan of care for resident;-The policy did not address timeframes for revising a resident's care plan after a change in condition.2. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated…

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 maintain professional standards of practice when staff failed to ensure prescribed medications were available and administered for one resident (Resident #3) out of two sampled residents. The facility's census was 230.1. Review of the facility's Medication Administration policy, dated 06/26/24, showed medications are administered by a licensed nurse, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. 2. Review of the facility's Transcription of Orders/Following Physician's Orders policy, dated 05/18/24, showed staff are directed as follows:-The Licensed/Registered Nurse will check the emergency kit to verify if the medication is present in the facility to begin immediately. If the medication is not available, the facility may contact the backup pharmacy to deliver the medication sooner. If the medication is unable to be started within 24 hours 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 interview and record review, facility staff failed to contact one resident's (Resident #1's) responsible party after the resident had a change in condition. The facility census 231. 1. Review of the facility's, Notification of Change policy, dated 05/14/24, showed:-The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification;-The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring Notification include accidents, resulting in injury or potential to require physician intervention.2. Review of Resident #1's Annual Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff used to assess the care needs of the resident, dated 06/20/25, showed staff assessed the resident as moderately cognitively…

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 with changes in the resident's needs for two residents (Resident #1 and #2) out of three sampled residents. The facility census was 231. 1. Review of the facility's policy, MDS 3.0, Care Assessment Summary and Individual Care Plans, dated 11/06/23, showed:-The Plan of Care should address improvements where possible and maintenance and prevention of avoidable declines and all Care Area Triggers;-There are twenty (20) areas that can become triggered areas for concern and must be addressed with individualized interventions on the plan of care for resident;-The policy did not address timeframes for revising a resident's care plan after a change in condition.2. Review of Resident #1's Annual Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff used to assess the care needs of the resident, dated 06/20/25, showed staff assessed the resident as moderately cognitively…

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 maintain professional standards of practice when staff failed to ensure prescribed medications were available and administered after admission from 07/18/25 to 07/21/25 to one resident (Resident #3) out of two sampled residents and failed to notify the physician to obtain further orders. The facility's census was 230.1. Review of the facility's policy titled, Medication Administration, dated 06/26/24, showed medications are administered by a licensed nurse, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. 2. Review of the facility's policy titled, Transcription of Orders/Following Physician's Orders, dated 05/18/24, showed: -The Licensed/Registered Nurse will check the emergency kit to verify if the medication is present in the facility to begin immediately. If the medication is not available, the facility may contact the backup pharmacy 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.

Based on observation, interviews and record review, facility staff failed to provide adequate nursing staff, as determined by their facility assessment. This had the potential to affect all residents. The facility census was 232. 1. Review of the Facility Assessment, dated 08/01/24, showed staff are directed as follows: -Direct care staff required to care for their facility census for a twenty-four hour period should include: Six Licensed Practical Nurses (LPN); Nine Certified Medication Technician (CMT); Twelve Certified Nurse Aides (CNA); Eight Nurse Aides (NA); and One Resident Care Coordinator (RCC). -The assessment is based on the resident population and their needs for care and support; -The last quarter average number of occupied beds was 235. Review of the employee staffing schedule from 01/19/25 through 02/04/25, with an average daily census of 235, showed: -Thursday, 01/30/25; six LPN's, ten CMT's, ten CNA's, six NA's and one RCC; -Sunday, 02/02/25; six LPN's, ten CMT's, thirteen CNA's, nine NA's and zero RCC; -Monday, 02/03/25; six LPN's, ten CMT's, thirteen CNA's, nine…

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 maintain professional standards of practice when staff failed to complete and document wound care treatments for two resident's (Resident #2 and #3) out of three sampled residents. The facility census was 232. 1. Review of the facility's Documentation of Wound Treatments policy, dated 05/18/24, showed wound treatments are documented at the time of each treatment. If treatment is not due, an indication on the status of the dressing shall be documented each shift. Additional documentation shall include, but is not limited to: Date and time of the wound management treatments; weekly progress towards healing and effectiveness of current intervention; Any treatment for pain; Modification of treatments or interventions; Notifications to physician and/or responsible party regarding wound or treatment change. 2. Review of Resident #2's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 12/11/24, 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.

Based on observation, interview and record review, the facility staff failed to allow sanitized dishes to air dry prior to stacking in storage to prevent the growth of bacteria and food contamination. Facility staff failed to maintain kitchen equipment and surfaces in two of two kitchens and one kitchenette in a clean sanitary manner to prevent cross-contamination and the growth of food-borne pathogens. The facility census was 233. 1. Review of the facility's Dietary-Equipment Operations, Infection Control, and Sanitation policy, revised on 02/02/24, showed the policy directed staff to air dry dishes by racking or putting on single trays lined with mesh after they are washed and sanitized. Observation on 10/21/24 at 10:31 A.M., showed 14 metal food service pans stacked together wet in the kitchen. Observation showed eight of the 14 wet stacked pans contained food debris inside them. Observation on 10/24/24 at 7:50 A.M., showed multiple plates stacked together wet upside down on a storage cart and 20 metal plate covers stacked together wet upside down on top of the toaster in 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 record review and interview, facility staff failed to prevent the commingling of 12 resident's (Resident #53, #85, #69, #102, #20, #181, #128, #98, #125, #216, #116, and #204) personal funds with the facility operating funds out of 79 sampled. The sampled resident's resided in the facility. The facility census was 233. 1. Review of the facility's policy titled Resident Rights, revised 07/05/23, showed the facility must establish and maintain a system that assures a full and complete separate accounting of resident's personal funds, the system must preclude any commingling of resident funds with facility funds. Review of the facility's policy titled Resident Trust, revised 11/08/23, showed the facility shall keep an accurate and maintained accounting system for the residents that choose to have their personal funds managed. These funds shall be safeguarded by the facility using complete and separate accounting principles, which precludes any commingling of resident funds with facility funds. Review of the facility's admission Agreement, undated, showed the facility must…

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 and interview, facility staff failed to provide refunds of personal funds to the residents from the facility operating account within 30 days for three residents (Resident #587, #588, and #585) out of five sampled who were discharged from the facility. The facility census was 233. 1. Review of the facility's policy titled Resident Rights, revised 07/05/23, showed upon the death of a resident the facility must convey within 30 days resident funds, and financial accounting of those funds to the individual or probate jurisdiction administering the resident estate. Within five days of the discharge of a resident, the facility will provide the resident or resident designee/guardian with an up-to-date accounting of resident funds. Upon the death of a resident the facility will provide an accounting to either the Department of Social Services or the fiduciary of the resident's estate. Review of the facility's policy titled Resident Trust, revised 11/08/23, showed upon a resident death the facility shall submit in writing a complete accounting of 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 and interview, facility staff failed to provide a comfortable and homelike environment for residents, when staff failed to maintain resident rooms, furniture in common areas, and ensure resident rooms did not contain piles of laundry. Staff failed to clean and maintain wheelchairs for three residents (Resident #137, #98, and #115) of 35 sampled residents. The facility census was 233 with a capacity of 239. 1. Review of facility policy titled, Housekeeping - Deep Cleaning, dated 06/29/23, show staff were directed as follows: -Deep cleaning is to be completed as scheduled. This includes complete pull-outs of furniture in rooms, wall cleaning, floor cleaning (scrubbing and waxing included), restrooms to be cleaned and disinfected, floors at closets and doorways are to be free from wax/dirt build up; -All areas should be monitored on a daily basis and all resident living areas and non-living areas should be clean and odor free; -Daily Cleaning: dust mop or sweep floor; clean bathroom using 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 interview and record review, facility staff failed to provide an ongoing activity program designed to meet the residents' interest, mental, and psychosocial well-being on the weekends for six residents (Resident #10, #73, #140, #141, #186, and #212) out of 35 sampled residents. The facility staff failed to post an activities calendar with accurate events for residents to view on Tiger Lane. The facility census was 233. 1. Review of the facility's policy titled Activity, dated 07/19/23, showed the purpose is to ensure all residents in the facility are provided an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, their interests and their physical, mental and psychosocial well-being. The Life Enhancement Director coordinates section F (Preferences of Customary Routines and Activities) of the comprehensive assessment and ensures the activities are designed to promote and enhance the emotional health, self-esteem, pleasure, comfort, education, creativity,…

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 ensure prepared food items were served at a safe and appetizing temperature when the facility staff failed to maintain the internal temperatures of hot food items at 120 degrees Fahrenheit (dF) or higher upon service to residents who resided on the 400 and 500 halls. The facility census was 233. 1. Review of the facility's Dietary Food Preparation policy, revised on 07/05/23, showed the policy directed staff to check the internal temperature of food items before service and the acceptable serving temperatures for hot foods were greater than 135 dF but preferably 160 dF to 170 dF. Review showed the policy directed staff to reheat food products to the proper temperature if temperatures do not meet acceptable serving temperatures. 2. Observation on 10/21/24 from 12:17 P.M. to 12:51 P.M., showed Dietary Aide (DA) EE prepared meal trays for the 400 Medical Hall. Observation showed the DA placed hot food from the steamtable on to room temperature plates, put the plates on a plastic service tray, covered 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 screen four employees (Dietary Aide S, [NAME] Y, Housekeeper N, and Activity Aide K) out of ten new employees prior to employment to determine if the employees had a federal indicator with the Employee Disqualification List (EDL) and/or the Family Care Safety Registry (FCSR). The facility census was 233. 1. Review of the Facility's policy titled Pre-Employment Screening, undated, showed the Human Resources department will conduct pre-employment screens on applicants to determine whether the applicant has committed a disqualifying crime, is an excluded provider of any Federal or State healthcare programs, is eligible to work in the United States, and if applicable, is duly licensed or certified to perform the duties of the position for which they applied. Human Resources will conduct the following screens on potential employees prior to hire: -Criminal History: Using the Request for Criminal Records Check, a criminal background check (CBC) should be done through the Missouri Highway Patrol's Missouri Automated Criminal…

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 document they administered three residents (Residents #115, #132 and #219) of 35 sampled residents medications and treatments. The facility census was 233. 1. Review of the facility's policy titled Transcription of Orders/Following Physician's Orders, dated 05/18/24, showed the nurse or Certified Medication Technician (CMT) in charge of medication administration must review all of their designated MARs and TARs prior to the end of their shift to ensure that all medications/treatments scheduled to be given on their shift were administered according to the physicians' order and that all necessary interventions were taken in the event of an omission Review of the facility's policy titled Documentation of Wound Treatments, dated 05/18/24, showed wound treatments are documented at the time of each treatment. If treatment is not due, an indication on the status of the dressing shall be documented each shift. Additional documentation shall include, but is…

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 document and update care plans to include the use of a colostomy bag (a bag that collects stool) for one (Resident #2) and new interventions for one resident (Resident #1) with a behavior of inserting foreign objects into his/her colostomy bag and stoma (opening in the body) out of four sampled residents. The facility census was 232. 1. Review of the facility's policy titled, Comprehensive Care Plans, dated 6/26/24, showed staff were directed to: -Develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment; -The comprehensive care plan will include measurable objectives and timeframe's to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized 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.

Based on interview and record review, facility staff failed to contact one resident's (Resident #1's) responsible party when the resident was transported to the hospital. The facility census was 236. 1. Review of the facility's Notification of Changes policy, dated 5/14/24, showed the purpose of this policy is to ensure the facility promptly informs the resident, consults the resident ' s physician, and notifies the resident's representative when there is a change that requires notification. Circumstances which requires notification are significant changes in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status which may include life threatening conditions or clinical complications. 2. Review of Resident #1's Significant change Minimum Data Set (MDS), a federally mandated assessment tool, dated 8/9/24, showed staff assessed the resident as: -Cognitively intact; -Surgical wound to Right Foot; -Diagnoses of metabolic encephalopathy, Diabetes Mellitus with other circulatory complications, encounter for orthopedic…

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 an infection prevention and control program to provide a safe and sanitary environment to help prevent potential spread of COVID-19 (an acute respiratory illness in humans caused by the coronavirus, SARS-CoV-2) and other infections, staff failed to protect residents in the facility when they did not follow acceptable infection control practices for COVID-19. The facility failed to separate residents who tested positive for Covid-19 from residents who had tested negative for Covid-19 or had only been exposed to Covid-19 for residents (Resident #40, #43, #21, #22, #27 and #9) at an increased risk of contracting Covid-19 due to prolonged exposure. Staff failed to wear the appropriate Personal Protective Equipment (PPE) with Covid -19 positive residents, removed PPE in appropriate areas and dispose of contaminated PPE appropriately. The facility census was 236. 1. Review of the Centers for Disease Control and Prevention (CDC)'s…

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

Based on interview and record review, facility staff failed to complete 72-hour neurological checks and fall follow up documentation for two residents (Resident #1 and #2) of four sampled residents, who had un-witnessed falls. The facility census was 233. 1. Review of the facility's Post Fall Protocol, revised 6/30/23, showed the purpose of the policy is to ensure all residents who have had a fall have accurate assessment and follow through to prevent further injury and recurrence of falls. Review showed neurological assessments include assessment of level of consciousness, movement of extremities, hand grasps, pupil size, pupil reaction, and speech. Review showed documentation of the resident fall must be completed in the risk management section and include but is not limited to documentation of the incident details, the time of the incident, the location of incident, equipment involved if any, residents activity at time of the incident. Continue neurological checks (if involved hitting head or was unwitnessed) every 15 minutes for one hour, every 30 minutes for one hour, 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.

Please refer to Event ID 2UWO12 Based on interview and record review, facility staff failed to ensure five residents (Resident #1, #4, #2, #3 and #5) of five sampled residents had the opportunity to make and receive phone calls in a private setting. The facility census was 234.

Please refer to Event ID 2UWO12 Based on observation, interview and record review, the facility staff failed to ensure five residents (Residents' #1, #2, #3,#4 and #5) are able to communicate freely with the state Abuse Hotline and Emergency Services. The facility census was 234.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews, facility staff failed to store and label food in a manner as to prevent spoilage and outdated use. Facility staff failed to maintain the main kitchen and three kitchenettes in a clean and sanitary manner. This failure had the potential to affect all residents. The census was 236. 1. Facility staff did not provide a policy to address food storage. Observation on 07/24/2023 at 9:58 A.M., of the main kitchen, showed the backsplash of the gas range had a build-up of black grease. Further observation showed food debris and paper products under the gas range. Observation on 07/24/2023 at 10:00 A.M., of the main kitchen, showed all five double door stainless steel refrigerators contained dried food splatter on the front of the doors. Observation on 07/24/2023 at 10:02 A.M., of the main kitchen, showed: -Two stainless steel containers on the bottom of double door fridge with green Jello, uncovered and and undated. One of the trays had a scoop and the handle down in…

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 resident dignity, when staff failed to cover two residents' (Resident #95 and #108) catheter drainage bags (bag that collects urine from the bladder), failed to keep the privacy curtain pulled for three residents (Resident #83, #159, and #687) when the lack of sheets/blankets left them exposed to the hallway, and failed to ensure three residents (Resident #112, #205, and #217) were dressed in clothing free from holes, stains, wrinkles, and facing the right direction. The facility census was 236. 1. Review of the facility's policy titled, Resident Rights, dated 07/05/23, showed each resident shall be treated with consideration, respect and full recognition of his/her dignity and individuality including privacy in treatment and in care for his/her personal needs. Review of the facility's policy titled, Catheter Care, dated 06/29/23, showed catheter bags are to be placed in privacy bags to promote dignity. 2. Review of Resident…

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

Based on interview and record review, facility staff failed to ensure five residents (Resident #1, #4, #2, #3 and #5) of five sampled residents had the opportunity to make and receive phone calls in a private setting. The facility census was 234. 1. Review of the facility's policy titled, Resident's Rights, dated 07/05/23, showed staff were directed as follows: -Privacy must include written and telephone communications; -Resident has the right to have reasonable access to the use of a telephone where calls can be made without being overheard. Review of the facility's, Phone Times schedule, undated, showed the following call times: -9:00 A.M. to 11:30 A.M. phone can be used; -11:30 A.M. to 1:00 P.M. no phone; -1:00 P.M. to 5:00 P.M. phone can be used; -5:00 P.M. to 7:00 P.M. no phone; -7:00 P.M. to 9:30 P.M. phone can be used. 2. During an interview on 09/15/23 at 10:00 A.M., Resident #1 said staff kept his/her cell phone locked inside the nurse's station, because he/she had issues. The resident said his/her Public Administrator (PA) did not want him/her to have the phone. 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 did not maintain a safe, clean, comfortable and homelike environment, when staff failed to ensure a comfortable sound level for residents by allowing the 400 and 500 hall entrance and exit doors to slam shut, failed to maintain one resident's (Resident #64) wheelchair, and failed to adequately clean and properly maintain residents' rooms, bed linens, furniture, bathrooms, windows and window coverings in good repair. Facility staff failed clean and maintain walls, trim and doors in community areas of the facility, used by residents. The facility census was 236. 1. Review of the facility's policy titled Maintenance Work Order, dated 12/21/22, showed a work order should be submitted for any issues that an employee observes which need the attention of facility maintenance. Reviewed showed when reviewing work orders, the facility maintenance department will assign each work order a priority, emergency is a one hour response, urgent is same day as…

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 failed to ensure four residents (Resident #1, #4, #3 and #5) of five sampled residents had the opportunity to make anonymous phone calls to the Department of Health and Senior Services (DHSS) Abuse and Neglect hotline. The facility census was 234. 1. Review of the facility's policy titled, Resident's Rights, dated 07/05/23, showed staff were directed to the following: -Resident Rights under Social Security Act, the resident has the right to communication with and access to persons and services inside and outside the facility; -Facility must provide reasonable access to any resident by any entity or individual that provides health, social, legal, or other services to resident; -Resident has the right to have reasonable access to the use of a telephone where calls can be made without being overheard. Review of the facility's, Phone Times schedule, undated, showed the following call times: -9:00 A.M. to 11:30 A.M. phone can be used; -11:30 A.M. to 1:00 P.M. no phone; -1:00 P.M. to 5:00 P.M. phone can be used; -5:00 P.M. to 7:00 P.M. no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to complete a Significant Change of Status Assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment tool, for one resident (Resident #235) who admitted to hospice services. Additionally, staff failed to accurately code MDS Assessments for three residents (Residents #112, #205 and #209) in regard to Activities of Daily Living (ADLs) needs, two residents (Residents #21 and #207), who used Continuous Positive Airway Pressure (CPAP), a machine that uses mild air pressure to keep airways open while sleeping, oxygen use for one resident (Resident #116), anticoagulant use for one resident (Resident #37) and insulin use for one resident (Resident #9). The facility census was 236 1. Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) manual, dated [DATE], showed: -A Significant Change in Status Assessment (SCSA) is required to be performed when a terminally ill resident enrolls 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 observation, interview and record review, facility staff failed to develop a comprehensive person-centered care plan for each resident to meet the residents medical, and nursing needs when they failed to address activity preferences for four residents (Resident #51, 76, 172, and 187), facial hair preferences for one (Resident #123), splint use for one resident (Resident #156) and hospice services for one resident (Resident #159). The facility census was 236. 1. Review of the facility's policy titled, Comprehensive Care Plans and Baseline Care plans, reviewed 01/19/22, showed staff were directed to do the following: -The purpose of this policy is to ensure that the facility must develops a comprehensive plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and mental and psychosocial needs that are identified in the comprehensive assessment; -Facility will use the Resident Assessment Instrument (RAI) User Manual 3.0 as a reference 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 review and revise the plan of care for three residents who required assistance with activities of daily living (ADLs) (Resident #64, #95, and #168), one resident who prefers to sleep during the day (Resident #21), and one resident (Resident #123) who used bed rails. The facility census was 236. 1. Review of the facility's policy titled, Comprehensive Care Plans and Baseline Care plans, reviewed 01/19/22, showed staff were directed to do the following: -Daily nursing meetings will occur Monday through Friday with a review of the resident's medical, functional and psychosocial problems. From this meeting, information will be individualized to the resident's plan of care; -The care plan with be oriented toward preventing avoidable declines in functioning or functional levels, evaluating treatment objectives and outcomes of care, respecting the resident's right to refuse treatment, using an interdisciplinary approach to care plan…

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 thirteen residents (Residents #21, #49, #51, #64, #76, #123, #126, #152, #156, #159, #164, #168, and #187), who were unable to complete their own activities of daily living (ADLs) (showering/bathing, dressing, and personal hygiene), received the necessary care and services to maintain good personal hygiene. The facility census was 236. 1. Review of the policies provided by the facility showed no ADL care, personal hygiene or shave/facial hair policy. Review of the facility's policy titled, Nail Care, dated 06/29/23, showed staff are directed to do the following: -Nail clipping or cutting must have an order from the nurse; -Certified Nurse Aides (CNA)s or Nurse Aides (NA)s should not cut the nails of diabetic patients or patients with Peripheral Vascular Disease (PVD) a disorder that narrows blood vessels to the extremities; -Responsibility and enforcement falls to the Director of Nursing (DON). 2. Review of Resident #21'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, facility staff failed to provide daily activities for all residents in the Turning Leaf Unit and failed to provide an ongoing program of activities designed to meet the residents' interests for three sampled residents (Resident #49, #159, and #687) on the [NAME] Hawk Boulevard hall. The facility census was 236. 1. Review of the facility's policy titled, Activity, dated 07/19/23, showed staff are directed to do the following: -Ensure all residents in the facility are provided an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, their interests and their physical, mental and psychological well-being; -The Life Enhancement Director coordinates section F (Preferences of Customary Routines and Activities) of the comprehensive assessment and ensures that activities are designed to promote and enhance the emotional health, self-esteem, pleasure, comfort, education, creativity, success and independence for all residents…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to propel four residents (Residents #83, #24, #187, and #95) in wheelchairs in a manner to prevent accidents. The facility census was 236. 1. Review of the policies provided by the facility showed no wheelchair safety policy. 2. Review of Resident #83's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 05/18/23, showed staff assessed the resident as follows: -Cognitively impaired; -Required extensive assistance from one staff member for locomotion; -Required extensive assistance from two staff members for transfers; -Had limited range of motion (ROM), joint movement, in all extremities; -Used a wheelchair. Observation on 07/25/23 at 8:35 A.M., showed Certified Nurse Aide (CNA) T propelled the resident from the dining area to his/her room without the use of foot pedals. The resident's feet dragged the floor. During an interview on 7/25/23 at 8:35 A.M., CNA T said the resident can propel himself/herself, but wants…

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 #1 and #156), and failed to provide appropriate catheter care (a flexible tube placed in the bladder to drain urine) for two residents (#95 and #108). Additionally, facility staff failed to clean and store respiratory equipment in a manner to prevent the spread of infection for two residents (Residents #21 and #207). The facility census was 236. 1. Review of the facility's policy titled, Handwashing, dated 06/29/23, showed staff were directed to do the following: -The use of gloves does not replace handwashing; -Hands are to be washed before and after gloving; -A waterless antiseptic solution may be used as an adjunct to routine handwashing; -Handwashing must be performed under the following conditions: -After having prolonged contact with a resident; -After handling used dressings, specimen containers, contaminated…

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 proper communication forms for one resident (Resident #231) who resides on the memory care unit. The facility census was 236. 1. Review of the facility's Communications with Persons with Limited English Proficiency policy, dated 06/30/23, showed staff were directed as follows: -Identify resident and their language; -Obtain a qualified interpreter; -Use family and/or friends as interpreters; -Provide written translation; -Monitor language needs. Review of Resident #231 admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 06/18/23, showed the staff assessed the resident as follows: -Language marked undetermined; -Able to make self-understood; -Able to understand; -Clear speech; -Adequate vision using corrective lenses; -Adequate hearing; -Marked as no if he/she should be asked activity preferences; -Required limited assistance with dressing; -Required limited assistance with personal hygiene; -Independent with bathing; -Diagnosis of Alzheimer's disease (brain disorder 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 interview and record review, facility staff failed to ensure one resident (Resident #198) received a meal or a snack prior to dialysis (process for removal of waste and excess water from the blood due to kidney failure) treatment. The facility census was 236. 1. Review of the facility's policy titled, Dietary-Medical Nutrition Therapy Policy, dated 2023, showed staff were directed to do the following: -The Dietary Technician/Dietary Manager will check all residents records for Diagnosis of Renal Failure; -After assessing residents identified to be at nutrition risk, a nutrition therapy plan is developed to meet identified needs and placed in the patient's chart; -Did not contain direction for staff in regard to dialysis. 2. Review of Resident #198's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 07/01/23, showed staff assessed the resident as follows: -Cognitively intact; -Diagnosis of renal failure; -Received dialysis. Review of the resident's Physician Order Summary (POS), July 2023, showed: -Dialysis every Tuesday, Thursday, and Saturday at…

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