Monarch Springs Wellness & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one resident with a history of elopement was provided with adequate supervision and staff oversight (Resident #2). On 3/10/26 at approximately 11:20 A.M., staff observed through the window that the resident was outside, across the street from the facility. The resident had a wanderguard (device that sets off an alarm when the person wearing it attempts to exit the facility) on his/her wheelchair and was able exit the building unnoticed through one of two exit doors on the second floor, which were alarmed but did not have a wanderguard sensor. The facility identified 10 residents who were at risk for elopement. The sample was 4. The census was 58. Review of the facility's Wandering and Elopement Policy, dated 08/2020, showed the following:-Purpose: To enhance the safety of residents of the facility;-Policy: The facility will identify residents at risk for elopement and minimize any possible injury as a result of…

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

Based on interview and record review, the facility failed to notify one resident's legal guardian of a change of condition and transfer to a hospital (Resident #3). The sample size was 4. The census was 45.Review of the facility's Change of Condition Policy, dated 1/2025, showed the following:-Purpose: To ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner;-Policy:- Definition: An acute change of condition (ACOC) is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains. Clinically important means a deviation that, without intervention, may result in complications or death;-I. Members of the Interdisciplinary Team (IDT) are expected to report and document signs and symptoms that might represent an ACOC;-II. The facility will promptly inform the resident, consult with the resident's Attending Physician, and notify the resident's legal representative when the resident endures a significant change in their condition caused by, but not…

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

Based on observations, interviews, document review, and facility policy review, the facility failed to ensure cleanliness and ensure food stored in one of one kitchen and in the unit nourishment room, was labeled, dated, and not expired. The failure had the potential to increase the prevalence and spread of foodborne illness and infection for 49 census residents. Findings include: Review of the facility's undated job description titled, Dietary Manager indicated it was the responsibility of DM to ensure compliance with regulatory standards during food preparation, storage, and service. Review of the facility's undated policy titled, Sanitation, indicated that the can opener should be cleaned after each use and unbolted from the table monthly to thoroughly clean the table where the base rests. Further review revealed that the ceilings need to be in good repair. 1. During an observation on 07/09/24 at 8:55 AM the following items were observed in dry storage and verified by [NAME] (C) 1 during the initial kitchen tour: -Eight re-packaged bags of cereal with no label or date. -Fourteen…

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

Based on interviews, and document review, the facility failed to ensure that a facility with more than 120 beds employed a full time qualified social worker which included a bachelor's degree in social work or a bachelor's degree in a human services field and one year of supervised social work experience. This failure has the potential to cause residents to not receive the necessary services to maintain as normal a possible lifestyle. Findings include: Review of the facility's undated job description titled, Social Worker Job Description, revealed The Social worker and/or social worker designee in a nursing home setting plays a crucial role in providing comprehensive social services to residents, their families, and caregivers. They assess residents' psychosocial needs, develop care plans, and coordinate services to enhance residents' quality of life and ensure their well-being. During an interview on 07/10/24 at 1:15 PM with the Administrator and Director of Nursing (DON), the Administrator revealed the facility was currently working with the local office to decrease the number 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 interviews and facility policy review, the facility failed to ensure infection control measures were appropriately implemented and maintained for Legionellosis assessment and prevention in the facility. This failure has the potential to affect 49 of 49 census residents. Finding Include: Review of website for ASHRAE [he American Society of Heating, Refrigerating and Air-Conditioning Engineers] titled Risk Management for Legionellosis, dated 10/15, located https://www.ashrae.org/, indicated .The design engineer first needs to evaluate which requirements of the standard apply to their project. This evaluation determines if the project contains any of the following building risk factors .Health-care facility with patient stays over 24 hours .Facilities designated for housing occupants over age [AGE] .The risk of disease or illness from exposure to Legionella bacteria is not as simple as the bacteria being present in a water system. Other factors that contribute to the risk are environmental conditions that…

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

Based on observation, interview, record review, and facility policy review, the facility failed to promote a dignified dining experience by serving beverages in disposable cups, and food on disposable plates at meals for one Resident (R) 24 and one of two dining rooms of 23 sample residents. This failure had the potential to affect all residents who were served meals prepared in the facility's one of one kitchen. Findings include: Review of the facility's policy titled, Dinnerware and Dining Services, revised 01/24, indicated, To ensure residents receive meals served consistent with proper dining expectations, in a clean and attractive setting and with oversight to support feeding needs. To comply with federal and state regulations governing dining services. 1. Observation on 07/09/24 from 12:35 PM to 1:25 PM, revealed residents in the 300-hall dining room were being served and eating their lunch meals. Further observations of the 300-hall lunch meal service revealed 18 of 22 residents eating in this dining room were served frosted cake on a small disposable Styrofoam plate and 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.

Based on observation, interview, record review, and facility policy review, the facility failed to maintain a clean and comfortable environment for two of the two dining rooms. This failure had the potential to affect all residents who ate meals in the facility's two dining rooms. Findings include: Review of the facility's undated policy titled, Housekeeping, indicated Cleaning Schedule and Protocols: Regular Cleaning: Specify the frequency and procedures for daily cleaning of resident rooms, common areas, bathrooms, and high-touch surfaces. Deep cleaning: Outline the procedures for periodic deep cleaning of carpets, upholstery, and other surfaces. 1. Observations of the facility's 300 hall dining room, during resident meal service, revealed the following concerns with the dining room's environment: a. Observation on 07/09/24 from 12:35 PM to 1:25 PM, revealed 22 residents were in the facility's 300 hall dining room being served and eating their lunch meals. Observations of the dining room's environment revealed chairs were stained and unclean with dried food spills, walls were…

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, interviews, and facility policy review, the facility failed to ensure expired medications and supplies were removed from one of one treatment carts, one of one medication rooms and failed to ensure one of one treatment cart and one of two nurse carts were locked. This had the potential to affect any resident who might be administered expired medications/use of expired supplies. The unlocked carts had the potential to be accessed by unauthorized residents, staff, and visitors. Findings include: Review of the facility's policy titled, Medication Labeling and Storage, dated 2001, indicated (2) The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner, and (3). If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. During an observation of the medication room for Hall 300 on 07/10/24 at 9:48…

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

Based on observations, interview, and facility policy review, the facility failed to ensure the facility's dumpster container lids were kept closed when not in use for 49 census residents. Findings include: The facility's undated policy titled, Sanitation indicated The Dietary Department will hold, transfer, and dispose of waste in a manner that does not create a nuisance or a breeding place for insects and rodents, or otherwise permit the transmission of disease .keep dumpster lids closed at all times and keep dumpster and dumpsite area clean and free of debris. During an initial tour observation on 07/09/24 at 8:55 AM, the dumpster container area, located on the side of the building, was observed. The dumpster container had two separate lids. One lid was observed open. Inside the dumpster there were multiple bags of garbage. The container was full, and the bags were visible over the top of the bin. Further observation revealed there was garbage on the ground around the bin. There was an odor around the area of the garbage bin. During an observation with the Dietary Manager (DM) on…

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, record review, and facility policy review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for one of three residents (Resident (R) 3) reviewed for Preadmission Screening and Resident Review (PASARR) of 23 sample residents. This failure placed the residents at risk of having unmet care needs and services. Findings include: Review of the facility's undated policy titled, PASARR Policy and Procedure. indicated In Missouri, PASARR (Preadmission Screening and Resident Review) is an essential process designed to ensure that individuals with serious mental illness (SMI) or intellectual disabilities (ID) receive appropriate care in nursing homes. Review of the Resident Assessment Instrument (RAI) Manual 3.0, dated 10/19, revealed .If an Minimum Data Set (MDS) assessment is found to have errors that incorrectly reflect the resident's status, then that assessment must be corrected . Review of R3's Face Sheet found under the Resident tab of the electronic medical…

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, record review, interview, and facility policy review, the facility failed to provide services based on acceptable standards of practice by specifically failing to accurately check a finger stick glucose level and failing to keep a clean field clean during wound care for two of two residents (Resident (R) 3 and R8) reviewed for professional standards of 23 sample residents. Findings include: Review of the facility's policy titled, Obtaining a Finger Stick Glucose Level, dated 2001, revealed . (8) Obtain a blood sample by using a sterile lancet (a spring-loaded lancet or manual lancet). Discard the first drop of blood if alcohol is used to clean the fingertips because alcohol may alter the results. Review of the facility's policy titled, Wound Care, dated 2001, revealed (4). Put on exam glove. Loosen tape and remove dressing. (5) Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. 1. Review of R3's Face Sheet located under the Resident tab 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, record review, and facility policy review, the facility failed to serve food that was palatable for three of four (Residents (R) 3, R12, and R24) reviewed for food palatability of 23 sample residents. This had the potential to affect 49 of 49 residents who consumed food that was prepared from the facility's kitchen. Findings include: Review of the facility's policy titled, Menus and Meal Preparation, with a revision date of 01/24, indicated Meals shall be prepared according [to] the facility approved menu. The menu shall be approved by the Licensed Registered Dietitian in the state of practice. Corresponding recipes shall be used in conjunction with meal service. When convenience or semi-convenience foods are prepared, the manufacturer directions shall be used in place of recipes. 1. Review of R24's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/29/24, located in the resident's electronic medical record (EMR) under the RAI (Resident Assessment Instrument) tab revealed a Brief Interview for Mental Status (BIMS) score of…

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

Based on interview and record review, the facility failed to provide a resident with an appropriate involuntary transfer discharge when they transferred one sampled resident (Resident #1) to the hospital and would not allow him/her to return, out of three sampled residents. The facility census was 51 residents. Review of the facility's admission Criteria policy, revised 03/2019, showed: -Our facility admits only residents whose medical and nursing needs can be met; Policy Interpretation and Implementation: -The objectives of our admission criteria policy are to: -Admit residents who can be cared for adequately by the facility; -Assure the facility receives appropriate medical records prior to or upon the resident's admission; -Prior to or at the time of admission, the resident or representative is informed of any service limitations or special characteristics of the facility; -Prior to or at the time of admission, the resident's attending physician provides the facility with information needed for the immediate care of the resident; -The acceptance of residents with certain…

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/or update one resident's care plan after each event of verbal and/or physical aggression, failed to update/revise interventions, and failed to train facility staff how to properly implement the residents current care planned interventions (Resident #1). The sample was 3. The census was 51. Review of the facility's Comprehensive Care Plan policy, revised 09/2010, showed: -Policy Statement: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident; -Enhance the optimal functioning of the resident by focusing on a rehabilitative program; -Reflect currently recognized standard of practice for problem area and conditions; -Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. When possible, interventions address the underlying…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure resident behavior triggers, which may have predisposed the resident's aggression, were adequately monitored and addressed. Staff did not develop interventions to address the resident's behavior to deter him/her from responding aggressively towards other residents and staff (Resident #1). The sample was 3. The census was 51. Review of the facility's Comprehensive Care Plan policy, revised 09/2010, showed: -Policy Statement: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident; -Enhance the optimal functioning of the resident by focusing on a rehabilitative program; -Reflect currently recognized standard of practice for problem area and conditions; -Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. When possible,…

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

Based on observations, facility policy review, and interviews, it was determined that the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety in the kitchen and during one of one meal service observed. Specifically, observations revealed the facility failed to : 1. Remove dented cans from the dry storage area; 2. Maintain food and refrigerator temperature logs; 3. Sanitize the thermometer between food items during observations of meal service ; and 4. Perform appropriate hand hygiene while plating food during meal service. This deficient practice had the potential to affect 33 of 36 residents of the facility that received food from the kitchen. Findings included: 1. A review of the undated Food Ordering and Receiving policy revealed, Leaking or severely dented cans should be stored separately to prevent contaminating other foods. If damaged when delivered, follow distributor policy for credit. During observations of the dry storage area of the kitchen on 12/06/2022 at 10:38 AM, seven dented cans were found among 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, record review, document review, and facility policy review, it was determined the facility failed to provide pharmaceutical services to establish and maintain a system to ensure drug records were in order and that accounted for all controlled drugs. Specifically, the facility failed to ensure narcotic medications were reconciled and loss or potential diversion was identified for 3 (Residents #19, #22, and #180) of 18 residents reviewed who were receiving narcotic medications. Findings included: A review of the facility policy titled, Controlled Substance, last revised December 2012, revealed, Nursing staff must count controlled medications at the end of their shift. The nurse coming on duty and the nurse going off duty must make a count together. They must document and report any discrepancies to the Director of Nursing Services. The Director of Nursing Services shall investigate any discrepancies in narcotic reconciliation to determine the cause and identify any responsibility…

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

Based on observations, interviews, and facility policy review, it was determined the facility failed to ensure controlled substances were stored in separately locked, permanently affixed compartments in 1 medication room; failed to ensure medications and biologicals were labeled in accordance with accepted professional principles on 2 of 2 medication carts; failed to ensure expired medications were not available on 1 of 2 medication carts; and failed to ensure an emergency drug kit was locked. Findings included: 1. A review of the facility policy titled, Controlled Substances, revised December 2012, revealed, 5. Controlled substances must be stored in the medication room in a locker container, separate from containers for any non-controlled medications. This container must remain locked at all times, except when it is accessed to obtain medications for residents. On 12/08/2022 at 10:22 AM, the medication room, located on the third floor, was observed. The medication room refrigerator was observed to contain a bottle of liquid Ativan (narcotic) with other medications. 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 employ a qualified social worker on a full time basis. The census was 34. Review of the State Operation Manual (SOM), showed a qualified social worker, for a facility with more than 120 beds defined as: An individual with a minimum of a bachelor's degree in social work or a bachelor's degree in a human service field including but not limited to sociology, gerontology, special education, rehabilitation counseling and psychology and one years supervised social work experience in a health care setting working directly with individuals. Review of the facility's license and certification records, showed the facility was licensed for 130 beds, of which 130 beds were certified for Medicaid and Medicare. Review of facility's current employee roster, showed the Social Service Designee (SSD) date of hire was 2/2/22. Review of the SSD's application, showed high school as the highest level of education attained. During an interview on 12/14/22 at 7:25 A.M., the SSD said she started in her position on 2/2/22. She currently covers…

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

Based on observations, interviews, record reviews, and review of facility documents, policies and Centers for Disease Control and Prevention (CDC) guidelines, it was determined that the facility failed to consistently implement infection control measures. Specifically, the facility: 1. failed to ensure staff were wearing appropriate personal protective equipment (PPE), per facility policy, when entering the room of 1 (Resident #13) COVID-19 positive resident of 5 sampled residents. 2. failed to ensure staff were wearing appropriate PPE, while handling soiled laundry in 1 of 1 laundry area to prevent potential cross-contamination of the staff member's clothing which could result in subsequent contamination of clean laundry. The facility census was 36. Finding included: 1. A review of a facility policy and procedure titled, Infection Control for All Nursing Procedures, revised August 2012, revealed, transmission-based precautions will be used whenever measures more stringent than standard precautions are needed to prevent the spread of infection. A review of a facility policy titled,…

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, interviews, record review, and facility policy review, it was determined the facility failed to ensure medication self-administration was assessed for 1 (Resident #279) of 16 sampled residents. Observations revealed medications were left at Resident #279's bedside; however, the facility failed to assess the resident to ensure self-administration was clinically appropriate. The facility census was 36. Findings included: A review of the facility policy titled, Administering Medications, revised April 2010, revealed, Medications may not be prepared in advance and must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). Further review of the policy revealed, 12. The individual administering the medication must initial the resident's MAR [medication administrator record] on the appropriate line after giving each medication and before administering the next ones. Continued review of the policy indicated, 18.…

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, interviews, and record reviews, it was determined that the facility failed to ensure the resident's right to receive services in the facility with reasonable accommodation of needs was met for 1 (Resident #3) of 3 residents reviewed for accommodation of needs. Observations and interviews revealed Resident #3 had a wheelchair that did not meet their positioning needs. Findings included: On 12/09/2022 at 5:01 PM, the Administrator (ADM) stated the facility had no policies related to the accommodation of residents' needs. A review of the Resident Face Sheet revealed the facility admitted Resident #3 with diagnosis that included multiple sclerosis (MS). The Resident Face Sheet further indicated Resident #3 was dependent on a wheelchair. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS further indicated that Resident #3 required extensive…

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

Based on interviews, record reviews, and policy review, it was determined the facility failed to ensure resident Minimum Data Set (MDS) assessments were completed and submitted timely for 3 (Residents #13, #8, and #22) of 3 residents reviewed for timely assessment transmission. Findings included: A review of the facility policy titled, Electronic Transmission of the MDS, dated September 2010, revealed, 5. MDS electronic submissions shall be conducted in accordance with current OBRA [Omnibus Budget Reconciliation Act] regulations governing the transmission of such data. 6. The MDS Coordinator is responsible for ensuring that appropriate edits are made prior to transmitting MDS data and that feedback and validation reports from each transmission are maintained for historical purposes and for tracking. A review of the facility policy titled, MDS Completion and Submission Timeframes, revealed, 1. The Assessment Coordinator or designee shall be responsible for ensuring that resident assessments are submitted to CMS' QIES [Centers for Medicare and Medicaid Services Quality Improvement &…

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, interviews, record reviews, and facility policy review, it was determined the facility failed to maintain all patient care equipment in safe operating condition for 1 of 4 mechanical lifts used in the facility to transfer residents. Observations revealed a mechanical lift was not properly working and staff failed to report the issue to maintenance staff. This deficient practice had the potential to affect nine residents in the facility who utilized mechanical lifts for transfers. Findings included: Review of a facility policy titled, Equipment Management Safe Medical Devices Act, undated, specified, Any device failure or user error that has had an adverse outcome the following procedure must be implemented: To ensure proper follow-up and investigation of the incident, the staff members who are aware of the incident will complete an incident report and forward it to the facility Administrator with (sic) 24 hours. The document further indicated Control settings, and any observed physical…

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.