Ridge Crest Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who required staff assistance with bathing received baths and/or showers to meet the needs of four sampled residents (Resident #1, Resident #3, Resident #4, and Resident #6) out of six sampled residents. The facility census was 50 residents. The facility was asked for the Bathing/Shower Policy and was provided with a copy of Code of State Regulations 19 CSR 30-85 (67 - 95). -The Administrator said the facility goes by the standard of care, generally two baths per week minimum, unless refused or care plan requests for one bath per week. 1. Review of Resident #1's admission Record showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Glaucoma (a group of eye conditions that can cause blindness). -Legal blindness (a significant level of vision impairment). Review of the resident's Care Plan dated 2/1/25 showed the resident did not have a Care Plan for Activities of Daily Living (ADLs) 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 ensure residents were adequately groomed by not offering showers or baths for four sampled residents (Resident #1, #2, #3, and #4) out of seven sampled residents. The facility census was 49 residents. Review of the facility' s undated Policy, Professional Standards of Care, showed: -Providing personal care for clients was the primary responsibility of the nursing assistant. -Often referred to as Activities of Daily Living (ADLs), personal care includes anything that a client needs to maintain hygiene, well-being, self-esteem, and dignity. -ADLs were the foundation of health and wellness and a part of providing holistic care. -Standard of two showers a week. -Residents had the right to refuse. -(Staff) would have revisited any refusals. -(Staff) would have care planned residents preference of showers. 1. Review of Resident #1's face sheet showed he/she had been admitted to the facility on [DATE] with the following diagnoses: -Unspecified…

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 have a certified Infection Preventionalist employed at the facility. The facility census was 49 residents. The facility did not have a policy for Infection Preventionalist. Record review of the Administrator's Certificate of Training dated 1/11/24 showed: -The Administrator had completed the first module of the Infection Prevention and Control Program on 1/11/24. -No other training was done. -He/She had not completed the Infection Prevention course. 1. During an interview on 8/6/24 at 12:45 P.M. Graduate Practical Nurse (GPN) A said: -They have had COVID (a contagious disease caused by the coronavirus SARS-CoV-2) in the building since he/she had started. -He/She did not know where the Personal Protective Equipment (PPE - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) was stored. -He/She had not received any education about COVID or what was expected of him/her when a resident became positive. -He/She did not know if the facility had an Infection Preventionalist. During…

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 and interview, the facility failed to ensure staffing was posted daily and accurately at the beginning of each shift including the total number and actual hours worked by licensed care staff which could have the potential to affect some residents and visitors in the facility. The facility census was 41 residents. 1. Review of the facility's policy titled Posting Direct Care Daily Staffing Numbers dated August 2022 showed: -The facility would post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents. -Within two hours of the beginning of each shift, the number of licensed nurses Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) and the number of unlicensed nursing personnel Certified Nursing Assistants (CNAs) and Nurse Aides (NAs) directly responsible for the care is posted in a prominent locations and is in a clear and readable format. -Shift staffing information is recorded on a form and includes the following: --The name of the facility. --The current date…

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 dietary department failed to have recipes available to process the following foods into a pureed (to make food into a paste or thick liquid suspension usually made from cooked food that was ground finely) form (peach crisp, chicken [NAME] pasta, and Italian Blend vegetables) potentially affecting three residents with pureed diets; and to provide a menu with a wider variety of choices for entrees, other than chicken, for the week 1 menu. This practice potentially affected all residents. The facility census was 41 residents. 1. Observation on 11/13/23 from 9:45 A.M. through 11:31 A.M., during the lunch meal preparation showed: - At 9:47 A.M., Dietary [NAME] (DC) A made pureed peach crisp with no recipe book open. - At 10:59 A.M., DC A made pureed vegetables with no recipe book open. - At 11:08 A.M., DC A made the pureed chicken [NAME] dish, with no recipe book open. During an interview on 11/13/23 at 1:38 P.M., the Dietary Manager (DM) said they have been…

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 and interview, the facility failed to discard a head of lettuce which turned brown; to label containers with a white powdery substance with what was in that container; to remove grime from the floor under the two compartment sink close to the walk-in refrigerator; to remove dirt and debris from behind the six-burner stove; to maintain 3 cutting boards without numerous nicks and in an easily cleanable condition; to maintain one mitten without a damaged area; to date containers of leftovers in the reach-in refrigerator with the date they were placed in the refrigerator; to label containers in the reach-in refrigerator with what the item was; and to maintain the faucet of the two compartment sink in good repair. This practice potentially affected all 41 residents. The facility census was 41 residents. 1. Observations on 11/13/23 from 9:14 A.M. through 12:35 P.M., showed: - One head of lettuce that was brown colored. - One unlabeled container with a green cover on the food preparation table with a white powdery substance in it. - One container of soup in the walk-in…

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

Based interview and record review, the facility failed to establish an infection prevention and control program (IPCP) that included an antibiotic stewardship program that addressed antibiotic use protocols and a system to monitor antibiotic use. The facility census was 41 residents. Review of the facility's policy, dated December 2016, titled Antibiotic Stewardship-Orders for Antibiotics showed: -Appropriate indications for antibiotic use included a culture and sensitivity (C&S-a culture is a test to find germs (such as bacteria or a fungus) that can cause an infection; a sensitivity test checks to see what kind of medicine, such as an antibiotic, will work best to treat the illness or infection) and having met the clinical definition of an active infection. Review of the facility's policy, dated December 2016, titled Antibiotic Stewardship-Staff and Clinician Training and Roles showed the Director of Nursing (DON) was to review all clinical documentation supporting antibiotic orders. 1. Review of the facility's Infection Control Log, dated August 2023, showed: -Staff listed 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 ensure an Infection Preventionist (IP) was designated and certified in infection prevention and control. The facility census was 41 residents. Review of the facility's undated policy titled Components of Infection Control showed the IP was to complete the required Center for Disease Control's (CDC) course on Infection Preventionist training. 1. During an interview on 11/13/23 at 8:59 A.M., the Administrator said: -He/she had not completed the IP course. -The facility did not have an IP as of 10/27/23. -He/she had been tracking infections in the building until a new IP could be found. -He/she had hired a new Director of Nursing (DON) as of 11/13/23. During an interview on 11/15/23 at 10:07 A.M., the Administrator said: -The DON had completed the CDC Infection Preventionist training. -The Regional Registered Nurse (RN) oversaw the program but hadn't been running it. -The Regional RN usually came in once a week but would come more often if needed. Review of the Regional RN's IP training records, received 11/15/23 at 11:08…

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 maintain the flooring in the restroom of resident room [ROOM NUMBER], in good repair; to maintain sprinkler heads in the dining room free of cobwebs; and to maintain the fan in resident room [ROOM NUMBER] and at the North nurse's station free of a dust buildup. This practice potentially affected at least 25 residents who resided in or used those areas. The facility census was 41 residents. 1. Observation on 11/14/23 at 9:37 A.M., with the Maintenance Director and the Housekeeping Supervisor, showed a 29 inch (in.) long section of flooring peeled away from the layer of floor underneath, in resident room [ROOM NUMBER] restroom. During an interview on 11/14/23 at 9:40 A.M., the Maintenance Director said the floor in resident room [ROOM NUMBER] was not in the maintenance log book to be repaired. 2. Observation on 11/14/23 at 10:40 A.M., with the Maintenance Director and the Housekeeping Director, showed the presence of cobwebs (a spider's web, especially…

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 follow facility policies and procedures for completing criminal background checks (CBC) within a timely manner and in accordance with the requirements prior to employing five of 10 employees sampled for the criminal background screening. The facility census was 41 residents. Review of the facility's undated Background Screening policy and procedure showed the facility conducts background screening checks, reference checks and criminal conviction investigation checks on applicants with direct access to residents. The procedure showed: -For purposes of this policy, direct access means any individual who has access to a resident patient of a long term care facility or provider through employment or through a contract and has duties that involve one on one contact with a patient or resident of the facility or provider, as determined by the state for purposes of the national background check program. -The director of personnel or designee conducts background checks, reference checks and criminal conviction checks on 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 observation, interview and record review, the facility failed to follow and document physician ordered wound treatments for one sampled resident (Resident #34) with a diabetic heel wound, and to ensure weekly skin assessments were completed per physician orders for two sampled residents (Resident #3 and #10) out of 12 sampled residents. The facility census was 41 residents. Review of the facility's Charting and Documentation Policy Revised July 2017 showed: -The following information is to be documented in the resident medical record: --Objective observations. --Changes in the resident's condition. --Events, incidents or accidents involving the resident. -Documentation in the medical record will be objective (not opinionated or speculative), complete and accurate. Review of the facility's Wounds Policy revised June 2021 showed a Weekly Skin Integrity Review form for staff to complete. Options included skin intact, bruises, rash, blisters, redness, skin tear with directions for staff to provide…

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 follow the physician's order for the amount of oxygen to be administered for three sampled residents (Resident #4, #26, and #1); to ensure orders were present for changing/cleaning oxygen supplies for four sampled residents (Resident #4, #26, #27 and #30); to ensure the humidifier was filled with sterile water for two sampled residents (Resident #4 and #26); to ensure oxygen administration and/or oxygen saturations (the amount of oxygen in the blood) were accurately documented for four sampled residents (Resident #4, #26, #1, and #30); and to properly store reusable oxygen equipment when not in use for five sampled residents (Resident #4, #26, #1, #27, and #30) out of 12 sampled residents. The facility census was 41 residents. Review of the facility's Oxygen Administration policy revised October 2010 showed: -Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen…

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 three Nurse Aides (NA A, NA B, and NA D) out of four NAs hired were certified to become Certified Nursing Assistants (CNAs) within four months of hire. The facility census was 41 residents. Review of the facility's policy titled Nurse Aide Qualifications and Training Requirements dated August 2022 showed the facility will not employ any individual as a nurse aide for more than four months full-time, temporary, per diem, or otherwise. 1. During an interview on 11/15/23 at 1:32 P.M. the Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) Coordinator said the facility had NAs, but was unsure of how long they had been working at the facility. During an interview on 11/15/23 at 1:37 P.M. the Administrator said: -He/she thought there was only one NA in the building, NA A. -He/she needed to verify when NA A had started the classes. Review of the facility's Hire Record Sheet dated 11/16/23 showed: -NA A was hired on 4/20/23. -NA B was hired on 12/14/22. -NA D was…

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 accurate documentation and reconciliation of narcotic medications for three sampled residents (Residents #30, #23 and #141) out of 12 sampled residents. The facility census was 41 residents. Review of the facility's Medication Administration Policy, last revised April 2019 showed: -The Director of Nursing Services (DON) supervises and directs all personnel who administer medications and/or have related functions. -Medications are administered in accordance with prescriber orders, including any required time frame. -The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. -As required or indicated for a medication, the individual administering the medication records in the resident's medical record: --The date and time the medication was administered. --The dosage. --The signature and title of the person administering the drug.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the treatment and medication carts remained locked when not in use and not within eyesight; to ensure medications kept in resident rooms were stored in a locked compartment for three sampled residents (Resident #26, #3, and #30); and to ensure residents had physician orders and were assessed to keep medications at bedside and to safely self-administer medications left at the bedside for two sampled residents (Residents #3 and #30) out of 12 sampled residents. The facility census was 41 residents. Review of the facility's Administering Medications Policy revised April 2019 showed: -Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so. -The director of nursing services supervises and directs all personnel who administer medications have related functions. -Medications are administered in accordance with prescriber orders, including any time frame. -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 observation, interview and record review, the facility failed to ensure the vegetables during the lunch meal on 11/13/23 and the eggs during the breakfast meal on 11/16/23, were maintained at or close to a temperature of 120 ºF (degrees Fahrenheit) at the time of service. This practice potentially affected at least 13 residents who received room trays on the north side of the facility. The facility census was 41 residents. 1. Observation on 11/13/23 from 11:33 A.M. through 12:17 P.M., during the delivery of lunch meal room trays showed: - At 11:33 A.M., the trays to be placed in the cart for the north hall, were loaded onto the cart. - At 11:46 A.M., Dietary Aide (DA) A placed the cart for the North Hall just outside the Main Dining Room (MDR). - At 11:55 A.M., 11:59 A.M., and 12:01 P.M., the cart for the north stayed in the same spot. The food cart stayed in the same spot for 16 minutes before Certified Nurse's Aide (CNA) D started to deliver room trays. - Between 12:01 P.M., and 12:17 P.M., CNA D…

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 pneumococcal (a name for any infection caused by bacteria called Streptococcus pneumonia-a bacteria that causes inflammation of the lungs) vaccinations were offered for three sampled residents (Resident #1, #14, and #9) out of 12 sampled residents. The facility census was 41 residents. Review of the facility's policy, dated March 2022, titled Pneumococcal Vaccine showed: -Staff were to assess each resident's vaccination status prior to admission or within five working days. -Staff were to provide education on the benefits and side effects of the vaccination and the education was to be documented in the resident's medical record. -If the resident or their representative refused the vaccine, appropriate information was to be documented by the staff in the resident's medical record, including the date of refusal. 1. Review of Resident #1's Face Sheet showed he/she was admitted with a diagnoses of Chronic Kidney Disease (CKD-a gradual loss of kidney function over time). Review of the resident's undated Care Plan 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 observation, interview and record review, the facility failed to ensure one sampled resident's (Resident #22) dignity by failing to ensure the placement of the resident's catheter bag (a catheter is a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid into a urinary collection bag) in a dignity/privacy bag so not to expose the contents of the bag out of 12 sampled residents. The facility census was 41 residents. Review of the facility Dignity policy and procedure dated February 2021, showed each resident should be cared for in a manner that promotes and enhances his/her sense of well-being, level of satisfaction with life and feelings of self-worth and self-esteem. The policy showed: -Residents are treated with dignity and respect at all times. -Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. -Demeaning practices and standards of care that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident with a pacemaker had physician's orders to follow up with cardiology and how often the resident's pacemaker (an electrical device that stimulates the heart at a fixed rate) was to be monitored via the resident's portable cardiac monitor for one sampled resident (Resident #10) out of 12 sampled residents. The facility census was 41 residents. Review of the facility's policy and procedures for Pacemaker, last revised on December 2015 showed: -Monitoring: --Monitor the resident for pacemaker failure by monitoring for signs and symptoms of [NAME] arrhythmias (slow, abnormal heart rhythm). --The pacemaker battery will be monitored remotely through the telephone or an internet connection. The resident's cardiologist will provide instructions on how and when to do this. --Make sure the resident has a medical identification card that indicates he/she has a pacemaker. The medical records must contain this information as well.…

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 the maintenance of one sampled resident's (Resident #18) hair care when he/she could not perform the care by him/herself out of 12 sampled residents. The facility census was 41 residents. Review of the facility's policy titled Activities of Daily Living (ADLs), Supporting dated March 2018 showed: -Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs. -Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming, personal, and oral hygiene. -Appropriate care and services will be provided for residents with the consent of the resident and in accordance with the plan of care. -Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals, and recognized standards of practice. -The resident's response to interventions will be monitored, evaluated, and revised as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a fall investigation was complete for one sampled resident (Resident #23) who fell on 8/2/23 to determine the root cause of the fall and to ensure an incident report and/or fall investigation was completed per facility policy for a fall on 8/24/23 in which the resident fell and fractured his/her right hip out of 12 sampled residents. The facility census was 41 residents. Review of the facility's policy titled Falls and Fall Risk, Managing dated March 2018 showed: -The staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. -The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. -The staff will monitor and document each resident's response to interventions intended to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the placement of one sampled resident's catheter (a catheter is a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid into a urinary collection bag) bag in a sanitary manner; to ensure the resident's care plan included catheter care interventions for one sampled resident (Resident #22); and to ensure one supplemental resident's catheter was kept below the resident's bladder during a transfer for one sampled resident (Resident #2) out of 12 sampled residents. The facility census was 41 residents. Review of the facility Catheter Care policy and procedure dated August 2022, showed the purpose was prevent urinary catheter associated complications, including urinary tract infections. The policy showed: -Position the urinary catheter drainage bag lower than the bladder at all times to prevent urine from flowing back into the urinary bladder. -Be sure the catheter tubing and…

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

Based on observation, interview, and record review, the facility failed to ensure dialysis (a life-saving procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) services were provide per the physician's order; and to ensure an order for the bandages to be removed from the access (the connection of an artery and vein used as a way to reach the blood to perform dialysis) after dialysis, were present for one sampled resident (Resident #27) out of 12 sampled residents. The facility census was 41 residents. A policy was requested on 11/16/23, in writing to the Administrator, and was not received at time of exit. 1. Review of Resident #27's Quarterly Minimum Data Set (MDS-a federally mandated tool used for care planning), dated 10/20/23, showed: -The resident was dependent on dialysis. -The resident was cognitively intact. Review of the resident's undated Care Plan showed staff were to monitor the resident's dialysis access. Review of the resident's Physician's Orders, dated November 2023, showed the physician ordered staff to monitor…

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 develop a comprehensive plan and offer appropriate food choices for one supplemental resident (Resident #26) to assist in losing weight out of 12 sampled residents. The facility census was 41 residents. Review of the facility's policy entitled Weight Assessment and Intervention dated 3/22, showed: - Resident weights are monitored for undesirable or unintended weight loss or gain. - Residents are weighed upon admission and at intervals established by the interdisciplinary team. - Any weight change of 5% or more since the last weight assessment was retaken. - Unless notified of significant weight change, the Registered Dietitian (RD) will review the unit record monthly to follow individual weight trends over time. - Undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight change has been met. The evaluation included the resident's target weight range, the resident's calorie protein 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 establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to include the following in its waterborne Illness plan: A plan on how to identify and mitigate waterborne pathogens in vacant rooms; what method the facility used to check for acceptable ranges for control measures; specific steps that would be taken in response to a Legionella ([NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis (all illnesses caused by Legionella) including a pneumonia-type illness called Legionnaires' disease) positive water sample; and a listing of the members of the water management team. This practice potentially affected all residents. The facility census was 47 residents with licensed capacity of 120 residents. Record 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.

Based on interview and record review, the facility failed to check the Nurse Aide (NA) Registry prior to their most recent hire date for six out of ten sampled employees to ensure they did not have a Federal Indicator (a marker given to a potential employee who has committed abuse, neglect, or misappropriation of property against residents) prohibiting them to work in a certified facility. The facility's census was 47 residents. Record review of the facility's Abuse Prevention Program dated as revised 2017 showed the NA registry would be checked prior to employment for each state where a NA has shown to have worked or has listed certification. 1. Record review of the facility's list of employees hired since the facility's last annual survey and the employees' employment files showed: -Employee A, a Certified Nursing Assistant (CNA), was hired on 4/21/22 and was checked against the NA registry on 7/5/18. -Employee D, a CNA, was hired on 3/8/22 and was checked against the NA registry on 8/18/21. -Employee E, a CNA, was hired on 2/21/22 and was checked against the NA registry 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 observation, interview, and record review, the facility failed to ensure residents were offered and/or received at least two baths or showers per week and to document when residents had showers or refused showers for four sampled residents (Resident #8, #18, #19, and #32) out of 12 sampled residents. The facility census was 47 residents. The facility did not have a policy related to providing bathing for residents. 1. Record review of Resident #8's face showed he/she was re-admitted to the facility on [DATE] with the following diagnoses: -Major depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living) -Muscle weakness. -Difficulty walking. -Cerebral aneurysm (a weakness in a blood vessel in the brain that balloons and fills with blood). -Migraine (a headache of varying intensity, often accompanied by nausea and sensitivity to light and sound). Record review of the resident's annual Minimum…

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 maintain the temperature of foods on breakfast trays delivered to the 300 and 400 Halls at or close to 120 degrees Fahrenheit (ºF ) for at least four residents who were served later in the process of serving. The facility census was 47 residents. 1. Observation of the breakfast meal delivery on 4/26/22 showed: -At 8:16 A.M., the cart with the breakfast meal trays for the 300 and 400 Hall, was delivered. -At 8:27 A.M., the temperatures of the foods on the test tray were the following: --The French Toast was 108 ºF. --The Sausage patties were 105.1 ºF. During an interview on 4/26/22 at 9:14 A.M., the Interim Dietary Manager said: -In the past, the dietary staff served meals with the regular ceramic plates on top of hot plates (a metal surface that is preheated and used for placing a ceramic plate on before the cover is placed over meal before delivery). -The last time someone from dietary tested a tray was about three weeks prior to the week of 4/26/22.…

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 the floor behind the ice machine was maintained free from food debris and grime; to ensure the sprinkler head in the walk-in refrigerator was free from a buildup of dust; and to ensure the handwashing sink located at the south side of the kitchen drained properly. This practice potentially affected 47 residents who ate food from the kitchen. 1. Observation on 4/26/22 from 5:58 A.M. through 9:23 A.M. showed: -Heavy buildup of a black colored grime, food particles, including an old piece of sausage patty, behind the ice machine. -A heavy buildup of dust on a sprinkler head in the walk-in refrigerator. -A slow draining handswashing sink located in the south side of the kitchen. During an interview on 4/26/22 at 7:03 A.M., Dietary [NAME] (DC) A said the sink started draining slow a few days ago. During an interview on 4/26/22 at 7:05 A.M., DA B said he/she did not notify the Maintenance Director about the slow draining sink. During an interview on 4/26/22 at 8:37 A.M., the Interim Dietary Manager (DM) said:…

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

Based on interview and record review, the facility failed to maintain records of authorization forms for two sampled residents (Residents #10 and #8) out of four sampled residents selected for the resident fund review, who allowed the facility to manage their funds. The facility census was 47 residents. 1. Record review of the authorization forms showed the absence of authorization forms (forms signed by residents to allow the facility to manage their funds) for Resident's #10 and #8. During an interview on 4/26/22 at 10:51 A.M., the Business Office Manager (BOM) said: - He/she had been in that position for about four weeks. - He/she was not aware of where the previous BOM stored the completed authorization forms for those residents.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify one sampled resident (Resident #21) out of four sampled residents selected for the resident fund review of a spend down plan to assist the resident in lowering his/her balances to within $200.00 of the eligibility limit of $5,035.00, The facility also failed to submit a Third Party Liability (TPL) form (a form which is sent to Missouri (MO) Health Net, which gives an accounting of the remaining balance of that resident's funds in the resident trust account), which is required to be sent within 30 days after death, to MO Health Net after the death of Resident #269. The facility census was 47 residents. 1. Record review of Resident #21's [DATE] Statement Register, showed a monthly balance of $5,025.38. Record review of Resident #21' [DATE] Statement Register, showed a monthly balance of $4,885.68. During an interview on [DATE] at 12:45 P.M., the Business Office Manager (BOM) said: - He/she had just started his/her position in [DATE]. - He/she was…

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 the facility's bed-hold policy notice when transferring the resident to the hospital for one sampled resident (Resident #29) out of 12 sampled residents. The facility census was 47 residents. Record review of the facility's bed-holds and returns policy dated March 2017 showed that prior to transfers, residents or resident representatives would be informed in writing of the bed-hold and return policy. 1. Record review of Resident #29's current face sheet showed the resident was admitted to the facility on [DATE], he/she was his/her own responsible party and some of his/her diagnoses included diabetes (a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin), respiratory failure (when fluid builds up in the lungs or when organs can't get enough oxygen-rich blood to function or when the lungs can't properly exchange carbon dioxide for oxygen) and pneumonia (a lung infection). Record review of the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide Diabetic (DM a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin) shoes (provide support and protection while minimizing pressure points on the feet) with inserts, in a timely manner resulting in a delay in the resident returning to the community and a decline in his/her over all well-being and attitude for one sampled resident (Resident #33) out of 12 sampled residents. The facility census was 47 residents. Record review of the facility's Foot Care policy, dated [DATE], showed: -Residents received appropriate care and treatment in order to maintain mobility and foot health. -Residents were provided with foot care and treatment in accordance with professional standards of practice. -Overall foot care included the care and treatment of medical conditions associated with foot complications including…

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 two sampled residents (Residents #38 and #96) were safely transferred from one surface to another by the staff using a mechanical lift out of 12 sampled residents. The facility census was 47 residents. Record review of the facility's policy, Lifting Machine, Using a Mechanical, dated July 2017 showed: -Two staff members were needed to safely move a resident with a mechanical lift. -Mechanical lifts may be used to transfer a resident from bed to a chair. -Staff must be trained and demonstrate competency using the specific machine utilized in the facility. -Slowly lift the resident, only lift as high as necessary to complete the transfer. -Gently support the resident as he or she was moved. -When the transfer destination was reached slowly lower the resident to the receiving surface. 1. Record review of Resident #38's face sheet showed he/she was re-admitted to the facility on [DATE] with the following diagnoses: -Anemia (a condition…

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

Based on observation, interview and record review, the facility failed to ensure food items which were brought in for residents, were labeled with a residents name and date in the North Side resident use refrigerator. This practice potentially affected at least two residents who had food items stored in that refrigerator. The facility census was 47 residents. Record review of the facility's visitor Food Policy entitled Foods Brought by Family/Visitors and revised in 7/17, showed: -Food brought to the facility by visitors and family is permitted . -Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents. -Food brought by family/visitors that is left with the resident to consume later will be labeled and stored in a manner that is clearly distinguishable from facility prepared food. -Perishable foods must be stored in resealable containers with tightly fitting lids in a refrigerator. Containers will be labeled with the resident's name, the item and the Use by date 1. Observation with Licensed Practical Nurse…

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 maintain the condition of two lids of the outdoor dumpsters to ensure they closed properly to prevent the dumpsters from being open. The facility census was 47 residents. 1. Observation with the Maintenance Director and the Housekeeping Account Manager on 4/25/22 at 3:29 P.M, showed a 9 inch (in.) crack and another lid with a 4 in. crack on two lids of the outdoor dumpster. During an interview on 4/25/22 at 3:30 P.M., the housekeeping Account Manager said the lids have not been cracked very long. During an interview on 4/25/22 at 3:31 P.M., the Maintenance Director said he/he was unaware of the broken lids of the dumpster. During an interview on 4/26/22 at 10:04 A.M., the Interim Dietary Manager said he/she did not notice the cracked lids on the outdoor dumpster containers Record review of the 2009 Food and Drug Administration (FDA) Food Code Chapter 5-501.110 entitled Storing Refuse, Recyclables, and Returnables, showed: Refuse, recyclables, and returnables shall be stored in receptacles or waste handling…

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 there was documentation from the Hospice (end of life care) company's visits which showed which services they had provided to the resident after 2/10/22; to have a signed Physician's order for Hospice services available in the chart, and to have a designated liaison from the facility to communicate with the Hospice company for one sampled resident (Resident #38) out of 12 sampled residents. The facility census was 47 residents. Record review of the facility's Policy, Hospice Program dated July 2017 showed Hospice providers who contract with this facility: -Must have a written agreement with the facility outlining in detail the responsibilities of the facility and the Hospice agency. -Were held responsible for meeting the same professional standards and timeliness of service as any contracted individual or agency associated with the facility. -Had the responsibility to provide medical direction, nursing, and clinical management of the terminal…

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.