Mary, Queen And Mother Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow acceptable infection control and prevention practices during personal care for three of four observations of personal care provided to incontinent residents (Residents #24, #43, and #68). In addition, the facility failed to follow their tuberculosis (TB, infectious lung disease) policy and procedures, for five of 10 employee sampled. The census was 106 with 103 residents in certified beds. Review of the facility's Hand Hygiene policy, dated [NAME] 5, 2020, showed: -All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility; -Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub; -Staff will perform hand hygiene when indicated, using proper techniques consistent with accepted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure care was provided in accordance with professional standards of practice for one resident when staff failed to have a dressing on the resident's coccyx as ordered (Resident #68). The sample was 21. The census was 106 with 103 residents in certified beds. Review of the facility's Provision of Physician Ordered Services policy, dated 12/8/17, showed: -Policy: The purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality; -Policy Explanation and Compliance Guidelines: - 1. Physician orders should be obtained for administration of all medications and treatments; -2. Registered professional nurse or licensed professional nurse under the direction of a registered professional nurse may carry out orders from a physician, physician assistant, nurse practitioner or clinical nurse specialist licensed by any state regulatory board…

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

Based on observation, interview and record review, the facility failed to ensure one resident, who was incontinent of bowel and bladder, received the necessary services to maintain good personal hygiene when the resident was assisted into his/her chair by the night shift and was not checked or cleaned of urinary and bowel incontinence until approximately seven hours later. The resident's brief was saturated with urine and bowel movement when assisted to be cleaned. The sample was 21. The census was 106 with 103 residents in certified beds. Review of the facility's Perineal Care policy, dated October 14, 2021, showed: -It is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown; -Perineal care refers to the care of the external genitalia and the anal area. Review of Resident #45's quarterly Minimum Data Set (MDS, a federally mandates assessment instrument completed by facility staff), 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.

Based on observation, interview and record review, the facility failed to ensure care was provided in accordance with professional standards of practice for one resident when staff failed to change the dressing on a left lower leg wound as ordered (Resident #45). The resident's left lower leg wound was not tracked by the facility for wound healing status and condition and staff failed document assessments of the wound. The facility identified 11 residents with non-pressure wounds. The census was 106 with 103 residents in certified beds. Review of the facility's Skin Assessment policy, dated November 11, 2017, showed: -Purpose: To ensure that residents who enter the facility without pressure ulcers, do not develop pressure ulcers, skin alteration, and to institute proper interventions; -A complete head to toe skin assessment will be performed on all residents by the charge nurse or designee upon admission/re-admission, then weekly and upon any change in condition of the skin. The charge nurse/designee will document the skin assessment and notify the physician and responsible party 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 failed to ensure each resident received assistance devices to prevent accidents, for one resident transferred without the use of a mechanical lift. Staff failed to use a gait belt and failed to ensure the resident was safe to transfer without the use of a mechanical lift. In addition, staff failed to evaluate the use of a Broda chair (medical reclining chair) with a tray for safety (Resident #62). The census was 106 with 103 residents in certified beds. Review of the facility's Safe Resident Handling/Transfers policy, revised 7/10/23, showed: -It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines; -All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. While manual lifting techniques…

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

Based on observation, interview and record review, the facility failed to ensure food was served palatable and at a safe and appetizing temperature during meal service by failing to maintain the temperature of hot food at least at 120 degrees Fahrenheit (F) for two of two meals sampled. The census was 128. 1. During an interview on 10/13/21 at 12:07 P.M., three of six residents in the rehab dining area said on a scale from one to ten, the food is rated a five and is often luke warm. 2. Review of Resident #102's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/13/21, showed: -Cognitively intact; -Diagnoses included non-traumatic brain dysfunction and anxiety disorder. During an interview on 10/12/21 at 1:00 P.M., the resident said the food is not the best. He/she had to ask staff to cut his/her food for him/her because it is served with plastic utensils and on Styrofoam. The facility has been serving meals like this ever since COVID-19 began. He/she would like regular utensils and plates. 3. Observation on 10/14/21 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure each resident is treated with dignity and respect. Staff complained about their workload and lack of knowledge of the job in front of a resident, called the resident's brief a diaper, talked about the resident's personal conditions loud enough for the roommate to hear, and talked amongst each other and not with the resident during care (Resident #102). Staff took a soda away from one resident without first discussing it with the resident or offering choices (Resident #84). Staff failed to ensure privacy during care when they failed to pull a privacy curtain resulting in a visitor walking into the room with the resident exposed and failed to close the window blinds as cars drove past the room during care (Resident #29). Staff failed to serve residents' meals timely in the main dining room as tablemates ate and staff stood over one resident to assist him/her with the meal (Resident #44). Staff failed to treat a resident with dignity…

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

Based on interview and record review, the facility failed to provide and maintain complete accounting records, regarding the petty cash kept on hand, for the resident trust account for 5 of 6 recorded months. In addition, the facility failed to keep an accurate record of the money kept in the petty cash bag. The census was 128. Review of the facility petty cash forms, dated 10/15/20, 12/21/20, 3/11/21, 5/6/21 and 7/2/21, showed no documentation of an accurate account of the coins and bills kept for the petty cash. Observation on 10/15/21 at 8:35 A.M., with Receptionist R of the petty cash bag, showed two envelopes. One with the amount of $54.95 written on it and one with the amount of $4.00 written on it. A count of the both envelopes showed a total dollar amount of $112.60. During an interview on 10/15/21 at 8:35 A.M., Receptionist R said she was the receptionist and did not really understand the petty cash bag. During an interview on 10/15/21 at 11:40 A.M., the chief financial officer said the receptionist and the business office manager should ensure the petty cash is balanced…

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

Based on interview and record review, the facility failed to maintain a surety bond for the resident trust fund account in the amount of one and one half times the average monthly balance for the past 12 months. The sample size was 25. The census was 128. Review of the resident trust account for the past 12 months, from October 2020 through September 2021, showed an average monthly balance of $94,000.00. This would yield a required bond in the amount of $141,000.00 (one and one half times the average monthly balance). Review of the bond report for approved facility bonds by the Department of Health and Senior Services (DHSS), dated 10/19/2016, showed an approved bond of $75,000.00. During an interview on 10/15/21 at 2:40 P.M., the administrator said the business office manager (BOM) is in charge of increasing the bond. The BOM is out of the office at this time. The increase on the statements were probably due to the stimulus checks. The administrator said she did not know the bond needed to be increased.

Based on interview and record review, the facility failed to develop and implement written policies and procedures that prevent abuse and neglect, when the facility failed to ensure proper staff screening for all staff, both facility staff and contracted staff. The facility's abuse and neglect policies failed to address when services are furnished under arrangement, with a registry, contracted, or temporary agency staff; the requirement to maintain documentation of the screening that has occurred. A resident (Resident #274) alleged physical abuse occurred. The facility conducted an investigation, was not able to substantiate abuse occurred, but identified a potential alleged perpetrator (AP), Certified Nursing Assistant (CNA) O who worked for a contracted agency. The facility failed to have an arrangement with the agency to ensure the facility had access to documentation that showed the agency staff had the appropriate screening to work for the facility and failed to ensure facility staff had the information needed to allow the department to conduct a complete investigation into 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, the facility failed to ensure the facility had a process to track personal belongings upon admission and through the residents stay and to ensure personal belongings were sent with the resident upon discharge. This resulted in one resident who was discharged from the facility, being discharged without all of their personal belongings (Resident #275). The census was 128. Review of the facility's Lost or Stolen Item policy, dated 10/14/21, showed: -When a resident and/or family member reports an item lost, a search is initiated for the missing item. If the item cannot be found and the facility is found to be responsible for the lost item, the resident is reimbursed for the lost item. And if need the facility helps replace the lost item; -When a resident and/or family member reports an item stolen, a search is initiated for the stolen item. If the item is determine stolen and not just missing, a self report is made for the item to the Missouri Department of Health and Senior…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the resident assessment accurately reflected the resident's status for nine of nine residents investigated for resident assessments who were coded as having restrains. The census was 128. Review of the facility's Resident Census and Conditions of Residents Centers for Medicare and Medicaid Services (CMS) form 672, completed by the facility on 10/12/21, showed: -Census 128; -Residents physically restrained: 0. Review of the Resident Assessment Instrument (RAI) manual, showed physical restraints defined as any manual method of physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. 1. Review of Resident #113's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/18/21, showed physical restraints, bed rail used daily.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible and that each resident receives adequate supervision and assistive devices to prevent accidents. Facility staff failed to ensure a resident was properly spotted and monitored during a Hoyer lift (mechanical lift) transfer for one of one Hoyer lift observation (Resident #102). Staff failed to ensure a low bed was used as indicated for one resident identified as a fall risk (Resident #87). In addition, staff failed to have a system in place to ensure all residents with a wander guard were accounted for, had appropriate orders for the wander guard, and that staff checked the function of the wander guard (Residents #33 and #44). The facility identified 9 residents with a wander guard. The sample was 25. The census was 128. 1. Review of the facility's Safe Resident Handling/Hoyer Transfer policy, dated 10/14/21, showed: -It is the policy of this facility to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents who are incontinent receive appropriate treatment and services to prevent urinary tract infections or other incontinence related complications for three of four perineal care (cleansing of the area between the legs to include the buttocks and genital area) observations. Staff failed to cleanse all areas potentially soiled, failed to ensure soap was rinsed from the skin and failed to ensure the area was dry to ensure the residents remained clean, dry and odor free (Residents #102, #47 and #29). The census was 128. Review of the facility's Perineal Care policy, dated 10/14/21, showed: -It is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible and to prevent and assess for skin breakdown; -Procedure: -Provide privacy by pulling privacy curtain or closing room door if a private…

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

Based on interview and record review, the facility failed to ensure each nurse aide had no less than twelve hours of in-service education per year, from hire date to hire date, for 4 of 10 sampled certified nursing aides (CNAs) reviewed. The survey findings identified failures related to CNA care for dignity, infection control, mechanical lift transfer safety and personal care. The census was 128. Review of the CNA training records, provided by the facility, showed: -CNA A hire date 11/18/19. Four hours of in-service training documented in the last year from hire date to hire date, from 11/2019 through 10/2020; -CNA B hire date 7/21/10. Zero hours of in-service training documented in the last year from hire date to hire date, from 7/2020 through 6/2021; -CNA C hire date 4/25/16. Zero hours of in-service training documented in the last year from hire date to hire date, from 4/2020 through 3/2021; -CNA D hire date 11/1/06. Eight hours of in-service training documented in the last year from hire date to hire date, from 11/2019 through 10/2020. During an interview on 10/18/21 at 10:23…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the monthly drug regimen review (DRR) recommendations were followed timely for one resident (Resident #57) and failed to ensure DRRs were completed monthly for one resident (Resident #79) who received psychotropic medications, for two of six residents investigated for DRR as part of the unnecessary medications investigation. In addition, the facility's policy failed to identify the timeframes for the different steps in the DRR process. The facility census was 128. Review of the facility's Drug Regime Review policy, dated 11/28/17, showed: -It is the policy of the facility that a licensed pharmacist will review the resident drug regimen including the resident chart at least once a month. The consultant pharmacist may need to conduct the medication regimen review more frequently depending on the resident condition, review of short stay residents and risk of adverse consequences. The licensed pharmacist will report in writing, any irregularities to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were not kept past their expiration date and treatment supplies and medications were properly labeled in four out of five medication carts observed and one of two medication rooms. The facility identified having two medication rooms and 10 medication carts. The census was 128. Review of the Medication Storage policy, dated 12/11/18, showed: -The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels; -These medications are destroyed in accordance with our Destruction of Unused Drugs Policy. 1. Observation on 10/14/21 at 1:20 P.M., of one of the two nurse medication carts identified in the [NAME] community, showed: -One opened bottle of a clear liquid, which appeared to be normal saline, located in the bottom drawer, with no lid. The label was peeled back, no open date when…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies as required. This had the potential to affect all residents with medical conditions or needs not addressed. The sample was 25. The census was 128. Review of the Facility Assessment, dated 1/16/21, showed: -Residents who do not communicate in the dominant language of the facility: 0 residents; -Who use non-oral communication devices: 0 residents; -With advance directive: 0 residents; -Diseases/conditions, physical/cognitive disabilities analysis: -Psychiatric/mood disorders: 0 residents; -Condition of the heart/circulatory system: 0 residents; -Condition of the neurological system: 0 residents; -Vision/visual loss: 0 residents; -Hearing loss: 0 residents; -Musculoskeletal system: 0 residents; -Neoplasm: 0 residents; -Metabolic disorders: 0 residents; -Respiratory system: 0…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections during two of four perineal care (the cleansing of the area between the legs to include the buttocks and genital area) observations, and when staff failed to properly sanitize shared medical equipment after use for two of three mechanical lift observations (Residents #102, #47 and #29), failed to wear an approved mask that completely covered their nose, used oxygen tubing on a resident that was lying directly on the floor, failed to change gloves after touching soiled surfaces and before touching clean dressing supplies, and served a resident a drink that had a staff person's hair in it (Residents #47, #29 and #44). The sample was 25. The census was 128. Review of the facility's Perineal Care policy, dated 10/14/21,…

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

Based on interview and record review, the facility failed to thoroughly investigate allegations of abuse for 1 of 5 abuse investigations reviewed. The facility failed to thoroughly investigate bruising found on a resident (Resident #64). The resident sample was 25. The census was 128. Review of the facility's abuse and neglect policy, dated 11/28/17, showed: -Investigate/Prevent/Correct/Alleged Violation: The facility must take the following actions in response to an alleged violation of abuse, neglect, exploitation, or mistreatment: -Thoroughly investigate the alleged violation; -Prevent further abuse, neglect, exploitation and mistreatment from occurring while the investigation is in progress; -Take appropriate corrective action, because of investigation findings; -Procedure: The investigation is the process used to try to determine what happened. The designated facility personnel will begin the investigation immediately upon identification of alleged abuse. A root cause analysis will be completed. The information gathered is given to administration; -Investigation of abuse: When…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized care plans, to address the specific needs of the residents, for 4 of 25 sampled residents (Residents #102, #16, #33 and #115). The census was 128. 1. Review of Resident #102's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 6/17/21, showed: -No cognitive impairment; -No mood or behaviors; -Supervision with eating; -Diagnoses included non-traumatic brain dysfunction and anxiety disorder. Review of the resident's physician order sheet (POS), dated 10/1/21 through 10/31/21, showed an order dated, 8/6/21 for a diet: Regular and thin liquids with meat cut for patient. Review of the resident's care plan, dated 9/14/21, showed the following: -Problem: Potential weight change due to diagnosis of failure to thrive; -Goal: Resident weight will remain stable for the next 90 days; -Intervention: Supplement per physician order and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain a physician order for a resident's full code status for one resident (Resident #79) of 25 sampled residents. The facility census was 128. Review of the Advance Directives Policy and Procedure policy, dated [DATE], showed resident wishes will be communicated to the staff via the care plan and to the resident's physician. Review of the Resident #79's admission Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated [DATE], showed: -Cognitively intact; -Required extensive assistance with mobility, toileting and personal hygiene; -Diagnoses included fractures, high blood pressure, diabetes, end stage renal disease (ESRD) and depression. Review of the resident's electronic medical record, showed a signed directive by the resident, dated [DATE], to perform cardiopulmonary resuscitation (CPR)/call 911 and hospitalization. Review of Resident #79's electronic physician order sheet, in use at the time of survey, showed…

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

Based on interview and record review, the facility failed to fully implement the facility's restorative therapy program and ensure residents received restorative therapy (RT) as ordered. The facility identified 57 residents that should receive RT services. Of those 57, two were sampled and concerns were found with one (Resident #115). The census was 128. Review of the facility's Restorative Nursing Program, dated 10/22/19, showed the following: -Policy: It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level; -Restorative Nursing Program, refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental and psychosocial functioning; -Policy Explanation and Compliance Guidelines: -All residents will receive maintenance restorative nursing services as needed by certified nursing assistants; -Restorative aides will…

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

Based on interview and record review, the facility failed to ensure that as needed (PRN) orders for psychotropic medications were limited to 14 days without further evaluation of the resident for one (Resident #79) of six residents sampled for the unnecessary medication review. The facility census was 128. Review of the Resident #79's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/26/21, showed: -Cognitively intact; -Required extensive assistance with bed mobility, toileting and personal hygiene; -Diagnoses included fractures, high blood pressure, diabetes, end stage renal disease (ESRD) and depression; -Antidepressant medication taken daily; -Opioid medication taken six of seven days. Review of the resident's electronic medical record, reviewed on 10/14/21, showed: -A scanned hand written order, dated 8/24/21, for Trazodone (antidepressant and sedative medication) 50 milligram (mg) to be given at bedtime PRN for insomnia; -The electronic physician order sheet order dated 8/24/21, for Trazodone 50 mg to be given 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.

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 26 opportunities observed, three errors occurred resulting in an 11.5% error rate (Residents #29 and #125). The census was 128. 1. Review of Resident #29's medical record, showed: -Diagnoses included peripheral vascular disease (poor blood flow to the extremities) and high blood pressure; -An order dated 6/8/21 and discontinued 10/12/21, for potassium chloride (supplement) 10 milliequivalents (mEq), 1 tablet once a morning; -An order dated 6/7/21 and discontinued 10/12/21, for Lasix (furosemide, water pill) 40 milligram (mg), 1 tablet once a morning. Observation on 10/14/21 at 9:35 A.M., showed Certified Medication Technician (CMT) X administered the resident's medications, to include potassium chloride 10 mEq and furosemide 40 mg. During an interview on 10/18/21 at 10:19 A.M., the Director of Nursing (DON) said if a medication has been discontinued, it should not be administered. 2. Review of the facility's Medication Administration via Enteral Tube…

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 to ensure each resident had fluids readily available during meal service, including one resident who had a current urinary tract infection (Resident #60). The resident sample was 25. The facility census was 128. 1. Review of the Resident #60's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/31/21, showed: -Cognitively intact; -Diagnoses included stroke, high blood pressure, diabetes, aphasia (difficulty swallowing), hemiplegia (weakness or paralysis on one side of the body), malnutrition and depression; -Limited assistance with eating with one person physical assistance. Review of the resident's care plan, revised on 8/3/21, showed: -Problem: Resident has a history of urinary tract infection; -Goal: Resident will not exhibit signs of urinary tract infection; -Approach: Ensure meticulous personal hygiene, especially after elimination. Review of the resident's progress notes, dated 10/7/21, showed responsible party discussed concerns regarding resident having…

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.