Springfield Skilled Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to document a change in condition and discharge to the hospital in one resident's (Resident #8) progress notes. The facility census was 106.1. Review of Resident #8's face sheet showed the following:-The resident admitted on [DATE];-The resident was his/her own responsible party;-Diagnoses included chronic obstructive pulmonary disease (COPD-a progressive lung condition causing airflow obstruction, leading to shortness of breath, cough (often with mucus), and wheezing, primarily from lung damage due to smoking or pollution), bipolar disorder (a serious mental illness causing extreme shifts in mood, energy, and activity), extrapyramidal and movement disorder (EPS-involuntary movement disorders, often caused by medications like antipsychotics), anxiety and insomnia. Review of the resident's quarterly MDS, dated [DATE], showed the following:-The resident was cognitively intact;-The resident required supervision or touching assistance for all activities 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.

Deficiency Text Not Available

Based on record review and interview, the facility failed to have the required minimum of six staff members attend the Quality Assessment Committee (QAA) meetings. The facility census was 98. Review of the facility's Quality Assurance Process Improvement (QAPI) policy showed the following: -QAPI takes a systematic comprehensive and data-driven approach to maintaining and improving safety and quality in nursing homes while involving all nursing home caregivers in practical and creative problem solving. -Responsibility of the interdisciplinary team to meet at a minimum of quarterly and as needed; -Best practice is to meet monthly; -The QAPI members shall include representatives from all departments in the interdisciplinary teams; -This also includes seeking input from residents, residents representatives, and frontline care staff. 1. Review of the facility's QAA minutes log showed the following QAA meetings held in 2024: -On 01/17/24, the Administrator, the Director of Nursing (DON), the Infection Preventionist (IP), and the Medical Director attended the QAA meeting; -On 02/14/24, 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, the facility failed to document an ongoing evaluation of bed rails and failed to complete regular inspections of the bed frame and side rails for risk of entrapment for one resident (Resident #2) whose side rails were loose. The facility failed to document identification and use of possible alternatives prior to use of side rails; failed to document assessing risk versus benefits of side rail use; failed to obtain informed consent for the use of side rails prior to installation; failed to care plan side rail use; and failed to complete initial and ongoing assessments to ensure the side rails were appropriate for use for two residents (Resident #12 and # 93 ). The facility census was 98. Review of the facility procedure titled, Restraints: Bed Rail Safety Check, undated, showed the following: -When using bed rails, close attention must be given to the design of the rails and the relationship between rails and other parts of the bed. Entrapment may occur in flat…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe and effective medication system in a manner that met the needs of each resident when staff failed to document administration of multiple doses of scheduled medications for three resident (Resident #1, #3, and #4) with no reason documented. In addition, staff documented administration of medications not available in the facility for administration for two residents (Resident #3 and #4). The facility census was 97. Review of the facility policy titled, Medication Administration-Preparation and General Guidelines, revised August 2014, showed the following: -Medications are administered in accordance with written orders of the prescriber; -A schedule of routine dose administration times is established by the facility and utilized on the administration records; -The individual who administers the medication dose records the administration on the resident's Medication Administration Record (MAR) directly after the medication 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.

Based on observation, interview, and record review, the facility failed to ensure residents only self-administer their medication once assessed by an interdisciplinary team and if clinically indicated when staff failed to observe one resident (Resident #28) take his/her medications, who had not been assessed for self-administration. The facility census was 98. Review of the facility's policy titled Self Administration of Medications, dated 12/2017, showed the following information: -If a resident desired to self-administer medications, an assessment was conducted by the interdisciplinary team (IDT) of the resident's cognitive, physical, and visual ability to carry out this responsibility during the care planning process. The resident should be re-assessed quarterly; -If the resident demonstrated the ability to safely self-administer medications, a further assessment of the safety of the bedside medication storage was conducted; -Bedside medication storage was permitted only when it did not present a risk to confused residents who wandered into rooms. When there was a safety concern…

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 the resident or resident representative with a Notice of Medicare Provider Non-Coverage (NOMNC-form CMS-10123) when all covered Medicare services were ending for two residents (Resident #62 and #98) and failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN - form CMS-10055) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for one resident (Resident #98) who remained in the facility after discharge from Medicare Part A services. The facility census was 98. Review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C-09-20), dated 01/09/09, showed the following information: -The Notice of Medicare Provider Non-Coverage (NOMNC, form CMS-10123) is issued when all covered Medicare services end for coverage reasons; -If the Skilled Nursing Facility (SNF) believes on admission or during a resident's stay that Medicare will not pay for skilled nursing or specialized rehabilitative services and the provider believes that an…

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

Based on observation, interview, and record review the facility failed to coordinate with the appropriate state-designated authority to ensure that individuals with a mental disorder, intellectual disability, or related condition receive care and services in the most integrated setting appropriate to their needs, when the facility failed to obtain and maintain a copy of a level II Pre-admission Screening and Resident Review (PASRR) for one resident (Resident #61). The facility census was 98. Review showed the facility did not provide a policy regarding PASRR requirements. 1. Review of Resident #61's face sheet (brief look at resident information) showed the following information: -admission date of 10/17/23; -Diagnoses included anoxic brain damage (occurs when the brain is deprived of oxygen for an extended period of time, leading to damage),cognitive communication deficit, anxiety, bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), schizoaffective disorder (a combination of symptoms of schizophrenia and mood disorder),…

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 services provided met professional standards of practice when the facility failed to obtain an order for, care plan, and monitor the use of a brace for one resident (Resident #12). Facility had a census of 98. 1. Review of Resident #12's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 11/17/22; -Diagnoses included cerebral infarction (stroke that occurs when the blood supply to part of the brain is blocked or reduced), hemiplegia (paralysis or weakness on one side of the body) of the left side, foot drop, and left ankle contracture. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 06/02/24, showed the following: -Cognitively intact; -Required set up and clean up assistance with personal and oral hygiene; -Dependent with dressing, transfers, toileting, showers, and mobility; -Used wheelchair for mobility. Review of the resident's 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, the facility failed to initiate a discharge summary for an anticipated discharge (a discharge that is planned and not due to the resident's death and/or emergency) for one resident (Resident #102). The facility census was 98. Review of the facility's policy titled Discharge Plan/Summary Voluntary, dated 11/01/18, showed the following information: -A physician order must be obtained; -If the resident is discharged home, the resident's community based physician is sent a copy of the residents Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), discharge summary (final summary of the resident's status which includes the residents most recent comprehensive assessment), physician order sheet (POS), progress notes, the resident's face sheet (brief look at resident information), advance directives, contact information for physicians, and any special precautions; -Social work should meet with the person accepting responsibility for 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, the facility failed to provide good grooming and personal hygiene for residents who were unable to carry out activities of daily living (ADL- basic care tasks that are essential for maintaining independence and daily life) for themselves when the facility failed to document bathing attempts for one resident (Resident #205), who was dependent on staff for bathing. The facility census was 98. Review of the facility's policy ADL Care Bathing, dated 07/21/22, showed the following information: -Nursing staff will assist in bathing residents to promote cleanliness and dignity; -The charge nurse will be made aware of residents who refuse bathing. 1. Review of Resident #205's face sheet (brief look at resident information) showed the following information: -admission date of 01/16/25; -Diagnoses included acquired absence of right and left below the knee, diabetes, anxiety, high blood pressure, and syncope and collapse (temporary loss of consciousness with a quick…

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, the facility failed to keep an environment free from accident hazards when staff did not complete and document a timely investigation or assessment into the cause of a coffee spill that resulted in a burn and did not update the resident's care plan timely regarding new interventions to prevent future burns for one resident (Resident #2). The facility census was 98. Review of the facility's policy titled, Accident and Incident Documentation and Investigation, revised 04/26/23, showed the following: -Accidents and/or Incidents involving residents will be investigated and documented on an Incident Report in the electronic health record (EHR). An incident is defined as an occurrence which is not consistent with the routine operation of the facility or the routine care of a particular resident. Accidents and incidents will be analyzed for trends or patterns to enable the facility to enhance preventive measures to reduce the occurrence of Incidents; -The licensed nurse assigned at the time of the resident care accident/incident was responsible 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.

Based on observation, interview, and record review, the facility failed to ensure catheters (a thin, flexible tube used to drain fluids, including urine, from the body) were only used when indicated and were maintained in a manner to prevent possible infection when staff failed to obtain an order with indication for use for an indwelling catheter, failed to obtain timely orders for catheter care, failed to complete the catheter care as ordered, and failed to care plan catheter use timely for one resident (Resident #95). The facility census was 98. Review of the facility policy titled, Catheter Care, dated 07/13/22, showed it was the the policy of the facility to maintain consistent and adequate hygiene standards for residents with an indwelling catheter to maintain function and prevention of infection or complications. 1. Review of Resident #95's face sheet (document that gives resident's information at a quick glance) showed the following: -admission date of 05/01/24; -Diagnoses included encephalopathy (brain disease that alters brain function and structure), cerebral infarction…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide respiratory care consistent with standards of practice and residents' care plans when staff failed to ensure staff changed oxygen equipment per physician order for two residents (Resident #12 and #83) and failed to include the use of oxygen on the care plan for one resident (Resident #12). The facility had a census of 98. Review of the facility policy titled, Oxygen Administration, undated, showed the policy did not address care of oxygen concentrators, humidifiers, or oxygen tubing. 1. Review of the Resident #12's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 11/17/22; -Diagnoses included cerebral infarction (stroke that occurs when the blood supply to part of the brain is blocked or reduced), hemiplegia (paralysis or weakness on one side of the body) of the left side, foot drop, and left ankle contracture. Review of the resident's annual Minimum Data Set…

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 maintain records that were complete for all residents, when staff failed to document how a burn occurred, and assessment of the burn for five days, and failed to document regarding the reason for a follow-up hospitalization for one resident (Resident #2). The facility census was 98. Review of the facility's policy titled, Accident and Incident Documentation and Investigation, revised 04/26/23, showed the following: -Accidents and/or Incidents involving residents will be investigated and documented on an Incident Report in the electronic health record (EHR); -The licensed nurse at the time of the incident was responsible for initiating/completing the Incident report; -The licensed nurse at the time of the incident was responsible for documenting the incident in the resident's medical record, in accordance with the guidelines below and set forth in the incident report. -The licensed nurse shall document the incident and notify the supervisor and Director…

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, record review, and interview, the facility failed to have a working call light system for all residents when the call light was not working properly in one resident room, affecting two residents (Resident #34 and #91). The facility census was 98. Review of the facility's policy titled, Resident Call System, revised 10/20/22, showed the following: -The facility call system relay calls directly to a centralized work area from the resident's bedside, toilet, and bathing area. The call system is accessible to a resident lying on the floor as required by state/federal guidelines; -During rounds nursing and the Interdisciplinary Team (IDT) members will ensure resident call systems are within reach of residents; -In the event the resident call system is down, call bells will be utilized until power is restored; -The Maintenance Director will complete routine call system inspections. 1. Review of the current resident room roster showed Resident #34 and Resident #91 shared a room. 2. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a written notice discharge, including the reason for discharge and right to appeal, to all resident upon discharge when the home failed to provide a written discharge notice to one resident (Resident #1) when they refused to accept the resident back to the facility after hospitalization. The facility census was 99. 1. Review of Resident #1's face sheet showed the following: -admission date of 05/13/19; -Diagnoses included paraplegia (paralysis that affects all or part of the trunk, legs, and pelvic organs), bi-polar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), type II diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), dysphagia oropharyngeal phase (difficulty swallowing), cognitive communication deficit, and schizophrenia (disorder that affects a person's ability to think, feel, and behave correctly). Review of 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, the facility failed to ensure sufficient staff present to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of residents when there was insufficient staff to answer call lights in a timely manner for four residents (Resident #2, #3, #4 and #5), in a review of 16 sampled residents. The facility census was 106. Review showed the facility did not provide a policy regarding answering call lights. 1. Review of the facility's Resident Council Meeting Minutes, dated 08/15/24, showed residents requested administration to hire more nursing staff. Review of the facility's Resident Council Meeting Minutes, dated 09/19/24, showed one resident complained of aides not answering call lights quickly enough. 2. Review of the facility census sheet, dated for 10/04/24, showed the following: -600 hall had 16 residents; -500 hall had 26 residents; -400 hall had 30 residents; -300 hall had 15 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.

Based on interview and record review, the facility failed to ensure all residents were treated with dignity and respect at all times when one staff member (Licensed Practical Nurse (LPN F)) raised his/her voice at one resident (Resident #1) and told the resident he/she could lose the right to smoke after a fall. The facility census was 106. Review of the facility's policy titles (Resident Rights), dated April 2023, showed the facility staff shall treat residents with kindness, respect, and dignity and ensure resident rights are being following. 1. Review of Resident #'1's face sheet showed the following: -admission date of 06/15/21; -Diagnoses included metabolic encephalopathy (brain dysfunction caused by a chemical imbalance in the blood that affects brain chemistry), personal history of traumatic brain injury (external force or blow to the head causing temporary or permanent brain dysfunction), acute kidney failure, cognitive communication deficit (difficulty with communication caused by impaired cognitive processes), schizoaffective disorder (mental health problem where you…

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 sufficient a fully functional call light system for all residents when the call lights for two residents (Resident #2 and #4) did not function properly. The facility census was 106. Review of the Facility's Resident Call System, dated 10/22, showed the following: -During rounds nursing an Interdisplinary Team (IDT) Member will ensure the resident call system is within reach of the resident; -In the event the resident call system is down, call bells will be utilized until power is restored; -The Maintenance Director will complete routine resident call system checks. 1. Review of Resident #'2's face sheet showed the following: -admission date of 10/25/23; -Diagnoses included respiratory failure (lungs cannot get enough oxygen), diabetes (body doesn't produce enough insulin), hemiplegia (paralysis or weakness on one side), and anxiety (feelings of fear or dread); -Resided on 300 Hall. Review of the resident's quarterly Minimum Data…

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 all abuse allegations were reported to the State Survey Agency (Department of Senior Services -DHSS) within two hours of staff being made aware of the allegation when the facility failed to report an anonymous allegation of possible verbal/mental abuse by a staff member to DHSS. The facility census was 110. Record review of the facility's protocol titled, Abuse Prevention, dated 08/30/18 and last revised 10/21/22, showed the following information: -Staff members, volunteers, family members, and others shall be encouraged to report incidents of abuse; -The Administrator and Director of Nursing (DON) must be promptly notified of suspected abuse or incidents of abuse; -Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, mental anguish, or emotional distress. This includes the deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being.…

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.

1. Please refer to event ID JJ94112 for citation details. Based on observation, interview, and record review, the facility failed to ensure a clean and homelike environment for all residents when staff failed to adequately and in a timely manner clean the floor of the resident room and failed to change the soiled bedding for one resident (Resident #2). The facility census was 110. Record review of the facility's policy titled, Resident Room Cleaning Procedures, dated 05/09/23, showed the following: -In each room bag and remove all trash from room. Clean inside and outside of trash cans when needed; -Always disinfect high touch areas in resident rooms; -Sweep bathroom and resident room floor, including under the bed. If the bed can be moved, move and clean the floor up against the wall; -Mop the resident room floor first and mop the bathroom floor last; -Identify and report any maintenance or cleanliness issues. Record review of the facility's policy titled, Cleaning Detail Forms, undated, showed the following: -Clean and disinfect the resident room using disinfectant cleaner 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 1. Please refer to event ID JJ94112 for citation details. MO00240384 Based on record review and interview, the facility failed to maintain a comprehensive person-centered care plan for all residents when staff failed to update the care plan for one resident (Resident #2) to include new information on communicating with the resident effectively when the resident returned from the hospital and failed to ensure all staff were aware of the change. The facility's census was 110. Review of the facility's policy titled, Comprehensive Person-Centered Care Plan, last reviewed 10/23/19, showed the following: -Each resident will have a person-centered plan of care to identify problems, needs strengths, preferences, and goals that will identify how the interdisciplinary team will provide care; -Comprehensive Person Centered Care Plan (CCP) contains services provided, preference, ability and goals for admission, desired outcomes, and care level guidelines; -[NAME] is part of the comprehensive care plan and is used as a tool…

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.

1. Please refer to event ID JJ94112 for citation details. MO00240384, MO00240390 Based on observation, interview, and record review, the facility failed to ensure staff provided necessary services for all dependent residents to maintain grooming and personal hygiene when staff failed to complete routine attempts to change urine-soaked clothing and complete bathing and/or showering for one resident (Resident #2) . The facility had a census of 110. Review of the facility's policy titled, ADL (activities of daily living) Care Bathing, dated 07/21/22, showed the following: -Nursing staff will assist in bathing residents to promote cleanliness and dignity. The charge nurse will be made aware of residents who refuse bathing; -Ensure bathing area is at a comfortable temperature; -Be gentle and do not rush the procedure. Allow for breaks if needed; -Encourage resident to bathe him/herself and assist as needed; -Assist with dressing/grooming as needed. 1. Review of Resident #2's face sheet (resident's information at a quick glance) showed the following: -admission date of 01/23/20;…

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.

1. Please refer to event ID JJ94112 for citation details. Based on observation, interview, and record review, the facility failed to ensure an environment as free from accident hazards as possible when staff failed to to place the call light in reach of one resident (Resident #1) as care planned for fa fall intervention. The facility census was 110. Review showed the facility did not provide a policy regarding care light accessibility. 1. Review of Resident #1's face sheet (a brief resident profile) showed the following: -admission date of 02/21/23; -Diagnoses included pyogenic arthritis (bacterial arthritis), schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly), chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), unspecified fracture of the kneecap closed with routine healing, unspecified abnormalities of gait and mobility, difficulty in walking, unsteadiness on feet, and localization-related (focal) (partial) idiopathic epilepsy (a type of epilepsy that occurs 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.

1. Please refer to event ID JJ94112 for citation details. Based on observation, interview, and record review, the facility failed to implement an effective infection control program when staff failed to clean urine on a resident's floor in a timely manner, stepped in the urine and walked through the facility without the cleaning of shoes, and left a resident's bare feet in a urine puddle for one resident (Resident #1). Staff also failed to clean the blood pressure monitor between making contact with the floor and using on one resident (Resident #1). The facility census was 110. Review of the facility policy's entitled, Blood/Body Fluid Spill, dated 07/21/22, showed the following: -The facility will clean and disinfect blood/bodily fluid spills following a two-step method; -This task is the responsibility of housekeeping, environmental services, and the Administrator; -Staff should clean spills in resident areas as soon as possible; -Staff should wash hands and wear appropriate PPE (personal protective equipment); -Staff should confine the spill and wipe it up immediately with…

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 maintain an ongoing monitoring process to include accurate documentation and accountability of expired or unusable medications, failed to ensure medications that could not be returned to the pharmacy were destroyed in a timely manner for eleven residents (Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11), and failed to develop a policy to address the proper documentation, destruction, and disposal of medications. The facility census was 105. Review of the facility's policy titled Controlled Substance Disposal, revised [DATE], showed the following: -Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility in accordance with federal and state laws and regulations; -The Director of Nursing, in collaboration with the consultant pharmacist, is responsible for the facility's compliance with federal 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.

1. Please refer to event ID JJ94112 for citation details. MO00240384, MO00240390 Based on observation, interview, and record review, the facility failed to ensure a clean and homelike environment for all residents when staff failed to adequately and in a timely manner clean the floor of the resident room and failed to change the soiled bedding for one resident (Resident #2). The facility census was 110.

1. Please refer to event ID JJ94112 for citation details. MO00240384 Based on record review and interview, the facility failed to maintain a comprehensive person-centered care plan for all residents when staff failed to update the care plan for one resident (Resident #2) to include new information on communicating with the resident effectively when the resident returned from the hospital and failed to ensure all staff were aware of the change. The facility's census was 110.

1. Please refer to event ID JJ94112 for citation details. MO00240384, MO00240390 Based on observation, interview, and record review, the facility failed to ensure staff provided necessary services for all dependent residents to maintain grooming and personal hygiene when staff failed to complete routine attempts to change urine-soaked clothing and complete bathing and/or showering for one resident (Resident #2) . The facility had a census of 110.

1. Please refer to event ID JJ94112 for citation details. MO00239914, MO00240161 Based on observation, interview, and record review, the facility failed to ensure an environment as free from accident hazards as possible when staff failed to to place the call light in reach of one resident (Resident #1) as care planned for fa fall intervention. The facility census was 110.

1. Please refer to event ID JJ94112 for citation details. MO00240390 Based on observation, interview, and record review, the facility failed to implement an effective infection control program when staff failed to clean urine on a resident's floor in a timely manner, stepped in the urine and walked through the facility without the cleaning of shoes, and left a resident's bare feet in a urine puddle for one resident (Resident #1). Staff also failed to clean the blood pressure monitor between making contact with the floor and using on one resident (Resident #1). The facility census was 110.

Based on observation, interview, and record review, the facility failed to ensure a clean and homelike environment for all residents when staff failed to adequately and in a timely manner clean the floor of the resident room and failed to change the soiled bedding for one resident (Resident #2). The facility census was 110. Record review of the facility's policy titled, Resident Room Cleaning Procedures, dated 05/09/23, showed the following: -In each room bag and remove all trash from room. Clean inside and outside of trash cans when needed; -Always disinfect high touch areas in resident rooms; -Sweep bathroom and resident room floor, including under the bed. If the bed can be moved, move and clean the floor up against the wall; -Mop the resident room floor first and mop the bathroom floor last; -Identify and report any maintenance or cleanliness issues. Record review of the facility's policy titled, Cleaning Detail Forms, undated, showed the following: -Clean and disinfect the resident room using disinfectant cleaner and cleaning clothes; -Clean the patient bed, raise and wipe down…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to maintain a comprehensive person-centered care plan for all residents when staff failed to update the care plan for one resident (Resident #2) to include new information on communicating with the resident effectively when the resident returned from the hospital and failed to ensure all staff were aware of the change. The facility's census was 110. Review of the facility's policy titled, Comprehensive Person-Centered Care Plan, last reviewed 10/23/19, showed the following: -Each resident will have a person-centered plan of care to identify problems, needs strengths, preferences, and goals that will identify how the interdisciplinary team will provide care; -Comprehensive Person Centered Care Plan (CCP) contains services provided, preference, ability and goals for admission, desired outcomes, and care level guidelines; -[NAME] is part of the comprehensive care plan and is used as a tool to make staff aware of the resident's daily care needs; -The CCP…

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 staff provided necessary services for all dependent residents to maintain grooming and personal hygiene when staff failed to complete routine attempts to change urine-soaked clothing and complete bathing and/or showering for one resident (Resident #2) . The facility had a census of 110. Review of the facility's policy titled, ADL (activities of daily living) Care Bathing, dated 07/21/22, showed the following: -Nursing staff will assist in bathing residents to promote cleanliness and dignity. The charge nurse will be made aware of residents who refuse bathing; -Ensure bathing area is at a comfortable temperature; -Be gentle and do not rush the procedure. Allow for breaks if needed; -Encourage resident to bathe him/herself and assist as needed; -Assist with dressing/grooming as needed. 1. Review of Resident #2's face sheet (resident's information at a quick glance) showed the following: -admission date of 01/23/20; -Diagnoses included unspecified intracranial injury with loss of consciousness (damage…

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 an environment as free from accident hazards as possible when staff failed to to place the call light in reach of one resident (Resident #1) as care planned for fa fall intervention. The facility census was 110. Review showed the facility did not provide a policy regarding care light accessibility. 1. Review of Resident #1's face sheet (a brief resident profile) showed the following: -admission date of 02/21/23; -Diagnoses included pyogenic arthritis (bacterial arthritis), schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly), chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), unspecified fracture of the kneecap closed with routine healing, unspecified abnormalities of gait and mobility, difficulty in walking, unsteadiness on feet, and localization-related (focal) (partial) idiopathic epilepsy (a type of epilepsy that occurs when abnormal neuronal activity is localized to a specific area of…

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

Based on observation, interview, and record review, the facility staff failed to ensure all residents were free from significant medication errors when staff failed to have a system to accurately document the timely administration of medications per professional standards when staff frequently documented two doses of medications administered at or near the same time and medication administered out of scheduled time frames for one resident (Resident #1), when the facility failed to have a policy related to a liberalized medication administration system, and when the facility failed to train nursing staff on a liberalized medication administration system. The facility census was 104. Review of the facility policy titled, Medication Administration-Preparation and General Guidelines, revised August 2014, showed the following: -Medications are administered in accordance with written orders of the prescriber; -A schedule of routine dose administration times is established by the facility and utilized on the administration records; -Medications are administered within 60 minutes 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 implement an effective infection control program when staff failed to clean urine on a resident's floor in a timely manner, stepped in the urine and walked through the facility without the cleaning of shoes, and left a resident's bare feet in a urine puddle for one resident (Resident #1). Staff also failed to clean the blood pressure monitor between making contact with the floor and using on one resident (Resident #1). The facility census was 110. Review of the facility policy's entitled, Blood/Body Fluid Spill, dated 07/21/22, showed the following: -The facility will clean and disinfect blood/bodily fluid spills following a two-step method; -This task is the responsibility of housekeeping, environmental services, and the Administrator; -Staff should clean spills in resident areas as soon as possible; -Staff should wash hands and wear appropriate PPE (personal protective equipment); -Staff should confine the spill and wipe it up immediately with absorbent (paper) towels, cloths, or absorbent granules (if…

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 maintain an effective infection control program when staff failed to don the appropriate Personal Protective Equipment (PPE - gloves, gowns, and masks) when entering isolation rooms with residents positive with influenza A, when staff failed to perform appropriate hand hygiene when exiting isolation rooms, and when staff failed to dispose of contaminated PPE properly. The facility census was 104. Review of the Center for Disease Control and Prevention's (CDC), Interim Guidance for the Use of Masks to Control Seasonal Influenza Virus Transmission, last reviewed 08/09/23, showed the following: -A combination of infection prevention control strategies are recommended to decrease transmission of influenza viruses in health care settings; -These include promptly placing suspected influenza patients in private rooms and having healthcare personnel wear PPE when caring for patients with suspected influenza; -Droplet precautions should be used…

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 provide a clean and homelike environment for all residents when staff failed to replace and/or fix the resident room walls and closet ceiling where a black substance was present in one resident's room (Resident #1). The facility census was 104. Review showed the facility did not provide a policy pertaining to maintenance of the building. 1. Review of Resident #1's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff), showed the following: -admission date of 12/07/23; -Resident required supervision or touching assistance with most activities of daily living (ADL's - dressing, grooming, bathing, eating, and toileting); -Diagnoses included pulmonary disease (a group of lunch diseases that block airflow and make it difficult to breathe. Observations on 01/31/24, at 10:30 A.M., of Resident #1's room showed the following: -The walls had a black substance between the bathroom and closet, between the two closets, and in the corner between the closet and the main door; -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 interviews, the facility failed to ensure all residents who required dialysis (a process of cleaning the blood by a special machine necessary when the kidneys are not able to filter the blood) services received care consistent with professional standards when staff failed to obtain orders related to dialysis services, failed to ensure the resident received scheduled dialysis services, failed to document monitoring due to missed dialysis services, and failed to notify the dialysis clinic and physician of the missed dialysis services for one resident (Resident #1). The facility census was 107. Review of the facility policy titled Physician Orders, dated 09/2022, showed the following information: -Orders must be recorded in the medical record by the licensed nurse authorized to transcribe such orders; -Physician orders must be documented clearly in the medical record; -Physician orders sheet will be maintained with current physician orders as new orders are received; -Physician orders will be transcribed to the appropriate administrator record; -Verbal orders…

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 have a fully functional call light system since August 2023, for resident Halls 100, 200, 300 and part of 400 Halls. The facility census was 111. Review showed the facility did not provide a policy addressing the call light system. 1. Review of facility records shows the following: -Weekly checks for call bell placement in resident rooms beginning 08/15/2023 through 11/13/2023; -On 08/09/23, quote to supply/install the parts to repair/replace non-functional nurse call system; -On 10/30/23, the company completed installation new equipment and connections. 2. Review of Resident # 1's face sheet (gives basic profile information) showed the following: -admission date of 09/15/22; -Diagnoses included cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), difficulty walking, muscle weakness, hemiplegia (paralysis that affects one side of the body) and hemiparesis…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to protect all residents from misappropriation of property when narcotic medications for multiple residents (including Residents #1, #2, #3, and #4) went missing while in the possession of the facility. The facility census was 108. The facility Administrator and the Director of Nursing (DON) were notified on 11/06/23 of the Past Non-Compliance which occurred on 11/06/23. The facility staff began an investigation on 11/06/23, suspended all involved certified medication technicians (CMT), notified the Department of Health and Senior Services (DHSS), local law enforcement agency, the pharmacy, and the residents' physicians. The facility made system changes that allow only nurses to have access to narcotics. The facility provided an in-service on misappropriation of property and the narcotic counting policy to all staff that access medications. The facility completed a complete medication audit and they reviewed the as needed narcotic medication…

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 document in residents' medical records notification of the physician regarding one resident's (Resident #1) refusal of medications and next of kin notification for one resident (Resident #2) following falls. The facility census was 110. 1. Review showed the facility did not provide a policy regarding physician notification with resident medication refusals. Review of Resident #1's face sheet (basic medical information sheet) showed the following information: -admission date of 08/03/21; -Diagnoses included residual schizophrenia (a subtype of schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) in which the individual has suffered an episode of schizophrenia,but there are no longer any delusions, hallucinations, disorganized speech or behavior), type two diabetes (a chronic condition that affects the way the body processes blood sugar), and anxiety (intense, excessive, and persistent worry and fear about…

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 neurological checks were completed per standards of practice after multiple falls involving, some involving head strikes, for one resident (Resident #2). The facility had a census of 110. Review of Saunder's Medical-Surgical Nursing, 4th edition, 2002, showed that neurological assessments (neuro checks) can detect early signs of central nervous system (brain) deterioration and are commonly done after a person sustains a head injury to detect complications. One of the most serious types of head injuries is a subdural hematoma, which consists of a collection of blood on the surface of the brain, and is an emergency condition. The purpose of performing neurological assessments is to establish a baseline upon which subsequent assessments can be compared and changes in neurological status can be determined. Review of the facility post-fall 72-hour monitoring report form, undated, showed the following monitoring intervals for assessment: -Initial assessment to be completed at the time of the fall; -Assessment every 15…

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 promote resident self-determination when staff failed to provide routine baths or showers to four residents (Residents #2, #19, #29, and #102). The facility had a census of 109. Record review of the facility policy titled, ADL Care Bathing, last reviewed on 7/21/22, showed the following: -Nursing staff will assist in bathing residents to promote cleanliness and dignity; -The charge nurse will be made aware of residents who refuse bathing. (The policy did not address how many showers per week residents should receive.) 1. Record review of Resident #19's annual Minimum Data Set (MDS - a federally mandated assessment tool completed by facility), dated 1/17/23, showed the following: -admission date of 4/19/18; -Diagnoses included of reduced mobility, history of UTIs (urinary tract infections), anxiety, and depression; -Cognitively intact; -Required extensive, one-person physical assistance for transferring, dressing, and personal hygiene; -Required…

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, the facility failed to notify the resident and the resident's representative in writing of a transfer or discharge to a hospital, including the reasons for the transfer, for seven residents (Resident #14, #25, #29, #35, #51, #88, and #161). The facility census was 109. Record review of the facility policy, titled Emergency Transfer Procedures, dated 10/07/2021, showed the following: -The family or responsible party will be notified of the transfer to the hospital by the nursing shift supervisor or designee; -A transfer form is used to accompany the resident to include medication information pertinent to the transfer, such as diagnosis, medications, diet, insurance information, responsible party, and a brief description of the resident's medical problem; -Document accordingly under nursing/progress notes. -The policy did not address the manner in which the responsible party will be notified. 1. Record review of Resident #25's face sheet (brief information sheet about the resident) showed the following: -admission date of 5/17/2021; -Diagnoses…

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, the facility failed to notify the resident and the resident's representative in writing of the bed hold policy when transferring residents to the hospital for seven residents (Resident #14, #25, #29, #25, #51, #88, and #161). The facility census was 109. Record review of the facility policy titled Resident Bed Hold, dated 11/15/2022, showed the following: -The facility will provide written information to the resident and/or the resident/representative regarding the bed hold policy prior to transferring a resident to the hospital or therapeutic leave as required by state and federal guidelines. 1. Record review of Resident #25's face sheet (brief information sheet about the resident) showed the following: -admission date of 5/17/2021; -Diagnoses included Type 1 diabetes (a chronic condition in which the pancreas produces little or no insulin), and quadriplegia (paralysis of all four limbs). Record review of the resident's nursing notes dated 1/20/2023, at 4:27 P.M., showed the following: -Resident left facility via Emergency Medical Services…

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 revise and update the comprehensive care plans for five resident (Resident #7, #25, #61, #66, and #88). The facility census was 109 Record review of the facility policy titled Comprehensive Person-Centered Care Plan, dated 10/23/2019, showed the following: -Each resident will have a person centered care plan to identify problems, needs strengths, preferences, and goals that will identify how the interdisciplinary team will provide care; -All disciplines will collaborate to develop a plan of care that meets the residents' needs, preferences, and goals; -The comprehensive person centered care plan contains services provided, preferences, abilities, and goals for admission, desired outcomes, and care level guidelines; 1. Record review of Resident #7's face sheet showed the following: -admission date of 7/27/2018; -Diagnoses included Type 2 diabetes (a chronic condition that affects the way the body processes blood sugar), acquired absence of right leg…

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

Based on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5% when the facility staff made five errors out of 26 opportunities resulting in an error rate of 19.2% error rate when staff failed to administer the correct amount of medication for one residents (Resident #43), when staff failed to ensure four residents (Resident #7, #35, #39, and #88) had a meal intake within 30 minutes of insulin administration, and when staff failed to administer insulin correctly for the four residents (Resident #7, #35, #39, and #88). The facility census was 109. Record review of the facility policy, titled Injectable Medication Administration, dated August 2018, showed the following: -Check order on the medication administration record to see that an injection is currently ordered or due; -Prepare the resident; -Prepare medication, assure label is attached, check expiration date, check vial for cracks, check that stopper is intact, and check contents for discoloration or other unusual appearance; -Check five rights as medication selected 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.

Based on observation, record review, and interviews, the facility failed to ensure residents were free of significant medication errors when staff failed to ensure four residents (Resident #7, #35, #39, and #88) had a meal intake within 30 minutes of insulin administration and failed to ensure staff administered the full dose of insulin to the four residents by not the holding insulin dose for 6 to 10 seconds at the site of administration as recommended by the manufacturer. The facility census was 109. Record review of the facility policy, titled Injectable Medication Administration, dated August 2018, showed the following: -Check order on the medication administration record to see that an injection is currently ordered or due; -Prepare the resident; -Prepare medication, assure label is attached, check expiration date, check vial for cracks, check that stopper is intact, and check contents for discoloration or other unusual appearance; -Check five rights as medication selected is checked against the order. Record review of the website Medscape (medical reference website 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 observation, interview, and record review, the facility failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious carrying contaminants, when staff failed to use appropriate hand hygiene after performing wound care for one resident (Resident #7), failed to use appropriate hand hygiene after performing incontinent care for three residents (Resident #7, Resident #33, and Resident #213), failed to use appropriate hand hygiene after performing glucometer (a machine used to check blood sugar) checks for two residents (Resident #29 and Resident # 262), and failed to use appropriate hand hygiene after performing glucometer checks and insulin injections for four residents, (Resident #7, Resident #35, Resident #39, and Resident #88). The facility also failed to properly clean/disinfect the shared glucometer between uses/residents. The facility census was 109. Record review of the Centers for Disease Control and Prevention (CDC) website, updated 1/30/2020, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to offer the pneumococcal vaccine to three residents (Resident #19, #35, and #44) following admission to the facility. Staff also failed to provide information and education to the residents or the residents' representatives of the risks and benefits of the pneumococcal vaccine. The facility census was 109. According to the Centers for Disease Control and Prevention (CDC) Pneumococcal Vaccine Timing for adults, dated 4/01/2022, showed the following recommendations: -Two pneumococcal vaccines are recommended for adults 65 years or older; -CDC recommends vaccination with the pneumococcal conjugate vaccine (PCV13 or Prevnar 13) for all adults 65 years or older and people two through [AGE] years old with certain medical conditions, including chronic (ongoing) conditions; -CDC recommends vaccination with the pneumococcal polysaccharide vaccine (PPSV23 or Pneumovax23) for all adults 65 years of older regardless of previous history of vaccinations with…

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

Based on observation, record review, and interviews, the facility failed to ensure the interdisciplinary team approved all self-administration of medication, obtained orders for the self-administration of medication and care planned the self-administration for one resident (Resident #78) with a medication at bedside The facility census was 109. Record review of the facility policy titled Medication Administration - General Guidelines:, dated December 2017, showed the following information: -Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so; -Five rights - right resident, right drug, right dose, right route, and right time, are applied for each medication being administered; -The medication administration record (MAR) is always employed during medication administration; -The MAR should contain supplemental information to help assure accurate dosing. Exampled could include location of medication. 1. Record review of Resident #78's face sheet included the following information: -admission…

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 clean and homelike environment for all residents when staff failed to adequately clean resident bathroom floors, repair, and maintain the bathrooms's of two residents (Resident #83 and #263). The facility census was 109. Record review showed the facility did not provide a policy related to cleaning and upkeep of the facility. 1. Observations on 1/27/23, at 1:57 P.M., showed tile on the floor of Resident #83's bathroom had been removed and the black area beneath was visible throughout. The walls of the bathroom were torn up and partially repaired with drywall putty/spackle. During an interview on 1/27/23, at 2:00 PM, the resident said the state of the bathroom bothered him/her. It was ugly, only partially repaired, and appeared dirty. He/She said the bathroom had been in the current state for as long as he/she had been a resident in the room. 2. Observation on 2/2/23, at 9:15 A.M., showed Resident #263's bathroom toilet to have brown discoloration on the floor surrounding the toilet, with broken…

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 protect the resident's right to be free from verbal abuse by staff when one staff member (Certified Nurse Aide (CNA) I) cursed at one resident (Resident #14). The facility census was 109. Record review of the facility policy titled Abuse Prevention, dated 4/28/21, showed the following: -The facility is committed to protecting the residents from abuse by anyone; -Identify, correct, and intervene in situations in which abuse and/or neglect if more likely to occur; -It is the responsibility of all staff to provide a safe environment for the residents. 1. Record review of the Resident #14's face sheet showed the following information: -admission date of 11/3/12; -Diagnoses included Type 2 diabetes mellitus (impairment in the way the body regulates and uses sugar (glucose) as a fuel) with diabetic neuropathy (nerve damage that can occur if you have diabetes), acquired absence (limb was amputated) of right leg below the knee, acquired absence of left leg below the knee, fracture of right middle of phalanx (bone of the finger),…

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 all allegations of abuse were reported immediately to management and within two hours to the State Survey Agency (Department of Health and Senior Services) when one resident (Resident #14) and one staff member reported an allegation of abuse against a staff member (Certified Nurse Aide (CNA I) to nurse who did not report to management or DHSS. The facility census was 109. Record review of the facility's protocol titled, Abuse Prevention, dated 4/28/21, showed the following information: -Staff members, volunteers, family members and others shall be encouraged to report incidents of abuse; -The Administrator and Director of Nursing (DON) must be promptly notified of suspected abuse or incidents of abuse; -If incidents occur or are discovered after hours, the Administrator and DON must be called at home or must be paged and informed of such incident; -Alleged violations involving abuse, neglect, exploitation or mistreatment, are reported immediately, but not later than two hours after the allegation is made. 1. Record…

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

Based on interview and record review, the facility failed to complete an a timely written investigation of an allegation of possible employee-to-resident abuse when one staff member and one resident (Resident #14) reported allegations of abuse again one staff member (Certified Nurse Aide (CNA) I) to a nurse. The facility census was 109. Record review of the facility policy titled Abuse Prevention, dated 4/28/21, included the following: -Staff members, volunteers, family members and others shall be encouraged to report incidents of abuse; -Suspected or substantiated cases of resident abuse, neglect, misappropriation of property, or mistreatment shall be thoroughly investigate, documented, and report to the physician, families, and/or representatives, and as required by state guidelines; -Report the results of investigation to the administrator or designated representative and other officials in accordance with state lay, including State Survey Agency, within 5 working days of the incident. 1. Record review of Resident #14's face sheet (brief information sheet about 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to electronically transmit encoded, accurate, and complete a Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument, completed by facility staff) to the Center for Medicare & Medicaid Services (CMS) System within 14 days after a facility completed a resident's discharge for one resident (Resident #71). The facility census was 109. 1. Record review of Resident #71's face sheet showed the following information: -admission date of 5/20/22; -Diagnoses included metabolic encephalopathy (problem in the brain, caused by a chemical imbalance in the blood), anoxic brain damage (brain injury caused by a complete lack of oxygen to the brain, which results in the death of brain cells after approximately four minutes of oxygen deprivation), history of falling, cognitive communication deficit, and generalized weakness. Record review of the resident's medical records showed the following: -On 5/20/22, staff documented the resident was admitted…

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 all assessments were accurate when staff failed to identity dialysis received by one resident (Resident #29) on his/her Minimum Data Set (MDS - a federally mandate assessment tool completed by facility staff). The facility census was 109. Record review of the facility-provided policy MDS 3.0, revised 10/1/19, showed the following: -The MDS Coordinator, in conjunction with the Interdisciplinary Team (IDT), is expected to complete assessments using the MDS 3.0 Resident Assessment Instrument (RAI) specified by the state in compliance with the MDS 3.0 RAI User's Manual guidelines; -Everyone completing a portion of the assessment must sign and certify the accuracy of the portion of the assessment he/she completed; -Upon completion of the assessment, a Registered Nurse is responsible for coordination and should sign to certify that the assessment has been completed. 1. Record review of Resident #29's face sheet (brief information sheet…

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.

2. Record review of Resident #35's face sheet showed the following: -admission date of 9/1/22; -Diagnoses included functional quadriplegia (refers to complete immobility due to severe physical disability or frailty without injury to the spinal cord), neuromuscular dysfunction of the bladder (lack of bladder control due to brain, spinal cord or nerve problems); cystostomy status (surgical creation of an opening into the bladder); and retention of urine (condition in which urine cannot empty from the bladder). Record review of the resident's physician order sheet (POS), current as of 2/3/23, showed the following: -An order, dated 9/3/22, for indwelling catheter (flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) care every shift related to neuromuscular dysfunction of the bladder and retention of urine. During an interview and observation on 1/24/23, at 8:58 A.M., the resident said that the staff change the catheter and catheter bag as needed. He/she said that he/she can empty the bag. The resident's catheter bag was 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, the facility failed to provide adequate activities of daily living (ADLs - dressing, grooming, bathing, eating, and toileting) to maintain good grooming when staff failed to provide routine showers to two dependent residents (Resident #21 and #32). The facility census was 109. Record review of the facility policy titled, ADL Care Bathing, last reviewed on 7/21/22, showed the following: -Nursing staff will assist in bathing residents to promote cleanliness and dignity; -The charge nurse will be made aware of residents who refuse bathing. (The policy did not address how many showers per week residents should receive.) 1. Record review of Resident #32's quarterly Minimum Data Set (MDS - a federally-mandated comprehensive assessment tool completed by facility staff), dated 1/10/23, showed the following: -admission date of 4/16/21; -Cognitively in tact; -Required total dependence of two ore more staff for transfer and toileting; -Required extensive assistance of one…

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 residents received necessary care to promote healing and prevent possible infection of wounds when staff failed to update the care plan regarding treatment and failed to perform hand hygiene during wound care for one resident's (Resident #7) pressure ulcer (injuries to the skin and underlying tissue primarily caused by pressure on the skin). The facility census was 109. Record review of the facility policy, titled Wound Management, dated 11/15/2022, showed the following: -The facility will provide evidence based treatments in accordance with current standards of practice and physician orders; -Wound treatments will be provided in accordance with physician orders; -Wound dressings will be applied in accordance with manufacturer's directions. Record review of the facility policy, titled Handwashing, dated 2/2016, showed the following: -Staff will perform hand hygiene for at least fifteen seconds by washing hands or using alcohol based hand rub under the following conditions: -When hands are visibly dirty…

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 have a physician order for use of oxygen, failed to care plan the use of oxygen, and failed to document use of oxygen on the Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff) for one resident (Resident #71). The facility census was 109. Record review of the facility policy titled Oxygen Administration and Storage, dated 1/1/2014, showed the following information: -It is the nurse's responsibility to provide emergency administration of oxygen when it is necessary the care of the resident; -The nurse will then call the physician as soon as reasonable to obtain a physician order; -Staff should verify the physician's order for oxygen prior to oxygen administration except in the case of emergencies. 1. Record review of Resident # 71's face sheet (brief information sheet about the resident) showed the following information: -admission date of 3/11/21; -Diagnoses included acute…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure all residents who required dialysis (a process of cleaning the blood by a special machine necessary when the kidneys are not able to filter the blood) services received care consistent with professional standards when staff failed to obtain orders related to dialysis services for one resident (Resident #29) and when the facility failed to have a contract with a dialysis provider for two residents (Resident #29 and #32) currently receiving dialysis services. The facility census was 109. Record review of the facility policy titled Dialysis Communication Transfer, dated 10/7/21, showed the following information: -A dialysis communication transfer form is completed each time a resident received outpatient dialysis. This ensured enhanced communication between the two facilities; -The top section of the form is completed by the nurse responsible for sending the resident to the dialysis facility; -The bottom section of the form is completed by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility staff failed to ensure food was palatable, attractive, and served at an appropriate temperature at the time the food was delivered to residents. The facility staff failed to ensure the nutritive value of all foods was maintained when staff failed to follow prepare pureed food according to the corresponding puree food instructions. The facility census was 106. 1. Record review of the facility's policy titled, Meal Service-Temperatures, dated 4/1/16 and revised 2/23/17, showed the following: -Meal temperatures shall be monitored by the Dietary Manager and the Cooks on a daily basis; -Temperatures shall be taken once food it placed on the steam table prior to the start of meal service; -Temperatures shall be taken at the end of the meal service to ensure temperature maintenance throughout service; -Food which registers temperatures outside acceptable range shall be removed and reheated or rechilled to meet acceptable holding and/or service…

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 a sanitary environment when the kitchen had two areas with standing water observed on multiple days. The facility census was 106. 1. Observation on 11/18/19, at 12:57 P.M., showed standing water covering an area approximately three to five feet wide underneath the cup storage racks in the kitchen. Observation on 11/22/19, at 8:56 A.M., showed standing liquid underneath the cup storage racks in the kitchen. The liquid was a light brown color. Observation on 11/22/19, at 9:00 A.M., showed standing water underneath a food preparation table near the reach in fridge along the back wall in the kitchen. Observation on 11/22/19, at 10:20 A.M., showed standing liquid underneath the cup storage racks in the kitchen. Observation on 11/22/19, at 10:58 A.M., showed standing water underneath a food preparation table near the reach in fridge along the back wall in the kitchen. Observation on 11/22/19, at 1:11 P.M., showed standing water underneath a food preparation table near the reach in fridge along the back…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure staff treated residents with dignity and respect when they did not provide dignity bags for two residents (Residents #33 and #66) with indwelling catheters (tubing placed internally to drain the bladder) and when staff failed to assist four residents (Residents #27, #35, #64, and #96) to dress in a dignified manner for dinner. A sample of 23 residents was selected for review; the facility census was 106. 1. Record review of Resident #33's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 9/4/19, showed the following information: -re-admitted to the facility from a hospital on 4/29/15; -Diagnoses included heart failure, Type II diabetes mellitus, dementia, Parkinson's disease (slowly progressive , degenerative, neurological disorder characterized by resting tremor, muscle rigidity and weakness), anxiety and depression; -Moderately impaired cognition; -Total dependence on staff…

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 notify the resident and the resident's representative in writing of a transfer or discharge to the hospital, including the reason for the transfer, for four residents (Resident #17, #30, #76, and #83), and failed to provide the ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) a copy of the notification for four residents (Resident #17, #30, #76, and #83). A sample of 23 residents was selected for review out of a facility with a census of 106. 1. Record review of Resident #76's Skilled Nursing Facility (SNF) progress notes did not showed staff did not make an entry for a transfer to the hospital on [DATE] or any progress note leading up to the transfer. Record review of the SNF to Hospital Transfer form dated [DATE], at 5:28 P.M., showed the resident transferred to the hospital for abnormal vital signs. Staff did not document any written notification made to the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide supervision and/or meal assistance for three residents (Residents #33, #35, and #64) who were identified as needing assistance with meals. A sample of 23 residents was selected for review in a facility with a census of 106. 1. Record review of Resident #33's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 9/4/19, showed the following information: -re-admitted to the facility from a hospital on 4/29/15; -Diagnoses included Type II diabetes mellitus, dementia, and Parkinson's disease (slowly progressive , degenerative, neurological disorder characterized by resting tremor, muscle rigidity and weakness), anxiety and depression; -Moderately impaired cognition; -Required extensive assistance for eating; -Record of weight loss of greater than 5% in the past month or 10% in the past six months, not on a physician-prescribed weight loss plan; -Required nutrition or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff and residents stored smoking supplies in a safe manner for four residents (Resident #17, #19, #69 and #83) selected for review out of a sample of 23 residents in a facility with a census of 106. Record review of the facility's smoking policy, dated 2/1/16, showed the following information: -Prior to, or upon admission, and as needed, residents and resident representatives shall be informed about any limitations on smoking, including designated smoking areas, and the extent the facility can accommodate their smoking or nonsmoking preferences; -All residents/resident representatives shall receive a copy of the smoking policy; -The facility will establish designated times to provide smoking times to residents requiring assistance and/or supervision; -The nursing staff will perform a smoking assessment upon admission, quarterly, and as needed. Nursing staff will consult with the attending physician and the Director of Nursing…

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 have sufficient nursing staff to meet the needs of the residents when call lights were not answered in a timely manner for residents. The facility census was 106. 1. Record review of the facility's resident council minutes, dated 9/12/19, showed the following information: -The residents said there is an issue with the facility not having enough staff; -The residents' call lights are not being answered in a timely manner. 2. During an interview on 11/18/19, at 12:30 P.M., Resident #120 said the facility needs more aides. It takes 30 to 40 minutes for staff to answer call lights. He/she has had to wait to use the bathroom, but has not had any accidents from it. 3. During an interview on 11/18/19, at 12:30 P.M., Resident #125 said staff are slow to answer call lights. 4. During interviews on 11/18/19, at 12:30 P.M., and 11/20/19, at 10:51 A.M., Resident #83 said the following: -It takes two hours for staff to administer a pain pill; -Staff…

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 conduct glucose meter control testing per nursing standards of practice which could affect insulin administration in a facility with a census of 106. Record review of the facility's policy, dated December 2015, titled Glucose Meter Control Testing, showed the following information: -Check dates on control bottle label and test strip via label (date when opened, good for 90 days); -Do not use control if three months past opened date or after expiration printed date on control bottle label; -Do not use test strips if 120 days past written opened date or after expiration date printed on test strip vial label; -Swirl or invert control bottle gently to mix control, do not shake; -Open test strip vial by pushing under lip of the vial cap, remove one test strip. Close vial immediately; -Use the vial strip quickly after removing the vial. Test strips left outside the vial too long will give an error message. If an error message appears, discard the strip and test with a new strip; -Control test should be performed 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 staff failed to ensure foods were held at an appropriate temperature to inhibit the growth of pathogens that can cause foodborne illness. The facility census was 106. Record review of the facility policy titled, Meal Service-Temperatures, dated 4/1/16 and revised 2/23/17, showed the following: -Meal temperatures shall be monitored by the Dietary Manager and the Cooks on a daily basis; -Temperatures shall be taken once food it placed on the steam table prior to the start of meal service; -Temperatures shall be taken at the end of the meal service to ensure temperature maintenance throughout service; -Food which registers temperatures outside acceptable range shall be removed and reheated or rechilled to meet acceptable holding and/or service temperatures; -The facility policy did not specify acceptable food holding temperatures for food. Record review of the United States Department of Agriculture (USDA) guidelines titled, Food Safety Basics revised 12/20/2016, showed hot food should be held at 140 degrees Fahrenheit…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review, the facility failed to document complete information in the resident's medical record regarding a significant change in condition and transfer to the hospital for one resident (Resident #76); information pertaining to the rationale and placement of an indwelling catheter (a sterile tube inserted into the bladder to drain urine) for one resident (Resident #33); and information regarding an episode of emergency dialysis (process of removing the excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally) for one resident (Resident #67). A sample of 23 residents was selected for review in a facility with a census of 106. 1. Record review of the mayoclinic.org website, showed the following information: -Diabetic ketoacidosis (DKA) is a serious complication of diabetes that occurs when the body produces high levels of blood acids called ketones; -The condition develops when the body cannot produce enough…

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

Based on interview and record review, the facility failed to report an allegation of abuse to the Department of Health and Senior Services (DHSS) within the required two hours timeframe when staff received an allegation of one resident (Resident #33) hitting another resident. The facility census was 106. Record review of a facility policy titled, Abuse Prevention, showed the following information: -Alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of an unknown source and misappropriation of a resident property are reported immediately, but not later than two hours after the allegations made, if the events that cause the allegation involve abuse or result in serious bodily injury; -If the events that cause the allegation do not involve abuse and do not result in in serious bodily injury, are reported immediately, but not later than 24 hours after the allegation is made, to the administrator of the facility and to other officials (including State Survey Agency, and local law enforcement as required); -Report the results of all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to complete a comprehensive discharge summary for one resident (Resident #105) who discharged to the community. Three residents were reviewed for discharge. The facility census was 106. Record review of a facility's policy entitled Discharge Planning Process (April 2017), showed the following information: -Purpose: Development and implementation of a discharge plan for residents interested in being discharged to facilitate safe transitions from the nursing center back to the community; -Evaluate the resident's discharge potential and needs; -Develop a discharge plan as part of the comprehensive care plan which includes: goals of care and treatment preferences, resident's interest in being discharge or transferred, needs upon discharge, capacity of the resident and care givers to meet the needs of the resident upon discharge/transfer, determine feasibility of discharge (who made decision and why), names of Interdisciplinary Team involved in developing 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, the facility failed to adequately assess, monitor, treat, and document a change of condition for one resident (Resident #76) out of a sample selection of 23 residents in a facility with a census of 106. Record review of the mayoclinic.org website, showed the following information: -Diabetic ketoacidosis is a serious complication of diabetes that occurs when the body produces high levels of blood acids called ketones; -The condition develops when the body cannot produce enough insulin. Insulin normally plays a key role in helping glucose, a major source of energy for muscles and other tissues; -Without enough insulin, the body begins to break down fat as fuel. This process produces a buildup of acids in the bloodstream called ketones, eventually leading to DKA if untreated; -DKA signs and symptoms often develop quickly, sometimes within 24 hours; -Symptoms may include excessive thirst, frequent urination, nausea and vomiting, abdominal pain, weakness or fatigue, shortness of breath, fruity-scented breath, confusion, high blood glucose level; -DKA…

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

Based on observation, record review, and interviews, the facility failed to ensure staff provided wound treatment for pressure ulcers consistent with professional standards of practice, to promote healing and prevent infection, and failed to consistently monitor the status of pressure ulcers for two residents (Residents #9 and #74). A sample of 23 residents was selected for review in a facility of 106. Record review of the facility's policy entitled Wound Care/Treatment Guidelines (revised 2009), showed the following information: -At weekly assessment should be done on all wounds requiring treatment. This should include measurement and a description; -Documentation of the treatment should be done immediately after the treatment; -The care plan should reflect the current status of the wound and appropriate goals. Record review of the facility's policy entitled Wound Care Procedure for Major Wounds (revised 2009), included the following information: -Wash hands and cut tape with clean scissors; -Put gloves on; -Remove the soiled dressing and place in a bag at the bedside; -Remove…

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 obtain physician orders and care plan the use and care of an indwelling catheter (a sterile tube inserted into the bladder to drain urine) for one resident (Resident #33). A sample of 23 residents was selected for review in a facility with a census of 106. 1. Record review of Resident #33's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 9/4/19, showed the following information: -re-admitted to the facility from a hospital on 4/29/15; -Diagnoses included history of urinary tract infections (UTIs); -Moderately impaired cognition; -Total dependence on staff assistance for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing; -Required extensive assistance for eating; -Occasionally incontinent of bowel and bladder; -No indwelling catheter present. Record review of the resident's nurse's note, dated 10/27/19, showed catheter care provided and found purulent (thick, milky) drainage around penis opening and Foley…

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, record review, and interviews, the facility failed to ensure one resident (Resident #67) had a physician's order indicating where and when the resident was to go to dialysis (a process of cleaning the blood by a special machine necessary when the kidneys are not able to filter the blood) treatment. A sample of 23 residents was selected for review in a facility with a census of 106. 1. Record review of Resident #67's face sheet (gives basic profile information) showed the following information: -admitted to the facility on [DATE]; -Diagnoses included end stage renal disease (Stage 5). Record review of the resident's Care Plan, initiated on 9/30/19 and current as of 11/26/19, showed the following: -A focus area of Chronic Renal Failure (CRF) and receiving hemodialysis (cleansing the blood by pumping it outside the body and through a filtering system) and at risk for complications; -Interventions: Arrange for resident's transportation to and from dialysis center on Tuesday, Thursday and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to complete a side rail gap assessment, to obtain a risk/benefit review, document alternatives attempted prior to use, document ongoing assessments, and/or failed to obtain informed consent for the use of side rails prior to use for two residents (Resident #69 and #17) out of a sample of 23 residents in a facility with a census of 106. 1. Record review of Resident #69's care plan, revised date 1/22/19, showed the following information: -Potential for impairment to skin integrity related to wheelchair use, incontinence of urine and bowel, and assistance with transfers and toileting; -The care plan did not address the use of a side rail. Record review of the resident's safety device audit assessment tool, dated 2/4/19, showed the following information: -The device did not restrict movement or prevent the resident from performing a movement they would otherwise be capable of performing; -The device assists in the improvement in 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.

Based on observation, record review, and interview, the facility failed to ensure staff administered medications with an error rate of less than 5%. Facility staff made two errors out of 27 opportunities for error, affecting two residents (Resident #65 and #76), resulting in an error rate of 7.4%. The facility census was 106. Record review of the facility's policy entitled Medication Administration: Subcutaneous Insulin (2007) showed to administer subcutaneous insulin as ordered and in a safe, accurate and effective manner. 1. Record review of Mosby's 2017 Nursing Drug Reference (30th ed.), showed Humalog (insulin lispro) is a rapid acting insulin and should be administered within 15 minutes before beginning a meal. The onset is 15-30 minutes with its peak at ½ to 1 ½ hours. Record review of Resident #65's current physician order sheet (POS) showed the following information: -An order, dated 12/22/18, to administer Humalog Solution (fast acting insulin), inject as per sliding scale subcutaneously (under the skin) before meals and at bedtime for diabetes; -Sliding scale as follows:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, staff did not document the results of the first step of a tuberculosis (TB) test in millimeters (mm) of induration on admission and did not complete the second step or a screening in lieu of the second step during a shortage of test solution for one resident (Resident #37). A sample of 23 resident was selected for review in a facility with a census of 106. Record review of the facility's policy entitled Infection Prevention Manual for Long Term Care, Section 9: Tuberculosis showed the following information: -All first time residents will be screened for infection with tubercle bacilli (TB) on admission, see the form Immunization and TB skin Testing Record; -Review of the form showed a space labeled results in mm/date; -Skin testing will employ the two-step procedure; -For purposes of interpretation, a reaction of greater than 10 mm induration is generally considered positive. 19 CSR 20-20.100 - General requirements for Tuberculosis Testing for Residents in Long-Term Care…

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.