Stonespring Of Vandalia

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, staff and resident interviews, and policy review, the facility failed to ensure medications were consumed at the time of administration. This affected one (Resident #40) of the three residents reviewed for medication administration. The facility census was 130. Findings include: Review of the medical record for Resident #40 revealed an admission date of 07/09/24 with medical diagnoses of local infection of skin, diabetes mellitus, morbid obesity, Chronic Obstructive Pulmonary Disease (COPD), hypothyroidism, and hyperlipidemia. Review of the medical record for Resident #40 revealed an admission Minimum Data Set (MDS) assessment dated [DATE], which indicated Resident #40 was cognitively intact and was independent with eating and bed mobility, required partial/moderate staff assistance with toilet hygiene, and supervision with transfers. Review of the medical record for Resident #40 revealed physician orders dated 07/09/24 for apixaban 5 milligram (mg) one tablet by…

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

Based on medical record review, observation, staff interview, and review of the facility policy the facility failed to ensure call lights were accessible to two (Residents #428 and #439) of 28 sampled residents. The facility census was 134. Findings include: 1. Review of medical record for Resident #428 revealed an admission date of 04/13/24 with diagnoses including chronic obstructive pulmonary disease (COPD), diabetes mellitus, dementia, and atrial fibrillation. Review of the Minimum Data Set (MDS) assessment for Resident #428 dated 08/19/23 revealed that the resident was cognitively impaired and was dependent on staff assistance for activities of daily living (ADLs.) Review of plan of care for Resident #428 dated 04/13/24 revealed the resident was at risk for an ADL self-care performance deficit related to atrial fibrillation, COPD, chronic kidney disease, glaucoma, and DM. Interventions included the following: assist with positioning to help maintain proper body alignment, encourage rest periods, keep call light within reach while in room. Observation on 04/17/24 at 7: 40 A.M.…

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 medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure carpet in resident rooms was maintained in a clean and sanitary manner. This affected one (Resident #421) of 28 sampled residents. The facility census was 134. Findings include: Review of medical record for Resident #421 revealed an admission date of 03/26/24 with diagnoses including skin cancer, atrial fibrillation, and post-traumatic stress disorder (PTSD.) Review of the Minimum Data Set (MDS) assessment for Resident #421 dated 03/26/24 revealed the resident was cognitively intact and was dependent on staff for assistance with activities of daily living (ADLs.) Observation on 04/15/24 at 11:00 A.M. of Resident #421's room revealed there were six large dark red stains on the carpet next to television and dresser stand. Interview on 04/15/24 at 11:00 A.M. with Resident #421 confirmed the stains on the carpet were made when he had fallen, and his blood had dripped all over the floor. Interview on 04/15/24 at 2:30 P.M. with State Tested…

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 medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure staff followed physician's orders for treatment of pressure ulcers. This affected one (Resident #429) of 17 facility-identified residents with pressure ulcers. The facility census was 137. Findings include: Review of medical record for Resident #429 revealed an admission date 04/12/24 with diagnoses including hemiplegia, hemiparesis, type two diabetes, and hypertension. Review of physician's order for Resident #429 dated 04/12/24 revealed an order for State Tested Nursing Assistant (STNA) to apply Remedy barrier cream after each incontinent episode. Review of physician's orders for Resident #429 dated 04/17/24 revealed an order to cleanse the pressure ulcer to the resident's sacrum with normal saline, pat dry with sterile gauze, cover with collagen, cover with gauze or abdominal pad, then secure with tape every day and night shift. Observation on 04/17/24 at 11:10 A.M. revealed Unit Manager (UM) #240 removed an old dressing that was saturated with urine 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 medical record review, observation, and staff interview, the facility failed to ensure non-edible products were secured and not accessible to residents with cognitive impairments. This affected one (Resident #94) of two residents reviewed for accidents. The facility census was 134. Findings include: Review of the medical record for Resident #94 revealed an admission date of 10/06/22 with diagnoses including dementia without behavioral disturbance, psychotic disturbance, mood disturbance, chronic obstructive pulmonary disease (COPD), acute respiratory failure with hypoxia, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment for Resident #94 dated 04/02/24 revealed the resident had severely impaired cognition and required supervision for eating, moderate assistance for oral hygiene, maximal assistance for personal hygiene, and was dependent on staff for toileting, bathing, dressing, bed mobility, and transfer. Review of the plan of care for Resident #94 dated 10/26/22 revealed the resident had impaired cognition and decision-making skills related to…

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

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure gastrostomy tube (g-tube) feedings were administered in a safe and proper manner. The affected one (Resident #86) of seven facility-identified residents with g-tubes. The facility census was 134. Findings include: Review of medical record for Resident #429 revealed an admission date of 04/12/24 with diagnoses including hemiplegia, hemiparesis, type two diabetes, cognitive deficit, and hypertension. Review of plan of care for Resident #429 dated 04/12/24 revealed the resident was at nutritional risk. Interventions included the following: administer tube feeding and flush per orders, maintain the head of the bed elevated 30 degrees during and thirty minutes after tube feeding, monitor and report signs and symptoms of aspiration. Review of plan of care for Resident #429 dated 04/12/24 revealed the resident required tube feeding related to dysphagia. Interventions included the following: administer tube feed and flush per orders, head of bed elevated 30 degrees…

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 medical record review, staff and resident interviews, and policy review, the facility failed to ensure medications were administered as ordered. This affected one (#134) out of the three residents reviewed for medications. The facility census was 129. Findings included: Review of the medical record for Resident #134 revealed an admission date of 03/16/22 with medical diagnoses of hypothyroidism, end stage renal disease, dependence on dialysis, chronic obstructive pulmonary disease (COPD), and diabetes mellitus. Review of the medical record for Resident #134 revealed a quarterly Minimum Data Set (MDS) assessment, dated 08/17/23 which indicated Resident #134 was cognitively intact. The MDS indicated Resident #134 required limited staff assistance with bed mobility and extensive staff assistance with transfers, toileting, dressing, and bathing. Review of the medical record for Resident #134 revealed a physician order, dated 08/16/23, for ipratropium-albuterol inhalation aerosol 20-100 microgram (mcg) per actuation (act), one inhalation by mouth three times per day on Monday,…

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, medical record review, resident and staff interview, and review of a policy, the facility failed to ensure medications were stored in a safe and secure manner. This affected one (#10) of one residents observed for medications. The census was 130. Findings include: Review of the medical record of Resident #10 revealed an admission date of 07/27/23. Diagnoses include hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominate side, anxiety, and depressive disorder. Review of the Minimum Data Set assessment dated [DATE] revealed Resident #10 was assessed with severely impaired cognition. Review of the October 2023 medication administration record (MAR) revealed Resident #10 was ordered the pain medication aspirin 81 milligrams (mg) one tablet, the supplement levothyroxine 137 micrograms (mcg) one tablet, the supplement selenium 200 mcg one tablet, the supplement vitamin D3 125 mcg one tablet, the antianxiety medication alprazolam 0.25 mg one tablet, the supplement…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a resident had the right to refuse treatment and failed to ensure the resident understood the intent of an advanced directive. This affected one (Resident #200) of three residents reviewed for advanced directives. The census was 128. Findings Include: Resident #200 was admitted to the facility on [DATE]. Diagnoses included chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease. Review of her Minimum Data Set (MDS) assessment, dated 08/01/23, revealed she was cognitively intact. Review of Resident #200 physician orders revealed she had an advanced directive of full code status from admission until 08/01/23. On 08/01/23, it was changed to Do Not Resuscitate Comfort Care (DNRCC) status. Review of Resident #200 progress notes, dated 08/01/23, revealed a note written by Nurse Practitioner #300 that stated, She is satting [oxygen saturation dropping] in the 50's. Put her on Cpap and told her that she needed to keep that 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 medical record review, observation, family, resident and staff interviews, review of night shift form and review of facility policy, the facility failed to ensure resident care equipment was maintained in a clean and sanitary manner. This affected two Resident's (#8, and #72) of two reviewed for environment. The census was 137. Findings include: 1. Review of the medical record for Resident #8 revealed an admission date of 10/19/15. Diagnoses included heart failure, vascular dementia and hypertension chronic kidney disease. Review of the Minimum Data Set (MDS) dated [DATE] revealed the resident was assessed as being cognitively intact with the need for extensive assistance of one person assist with activity of daily living (ADLs). Interview with Resident #8 on 03/10/20 at 10:03 A.M. revealed she felt staff did not clean her wheelchair very often and she was unable to do it herself. Observations of Resident #8 in her wheelchair on (03/10/20, 03/11/20, 03/12/20) at various times revealed her wheelchair…

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 closed medical record review, staff interview and review of facility policy, the facility failed to ensure a safe discharge for residents when staff sent home medications not prescribed to the discharging resident. This affected one (Resident #15) out of five residents reviewed for a safe discharge. The current census was 134. Findings include: Review of Resident #15's closed medical record revealed the resident was admitted to the facility on [DATE] and discharged home on [DATE]. Diagnoses included fracture of the femur, dysphagia, hypertension, heart disease, and history of falls. Review the comprehensive admission Minimum Data Set (MDS) dated [DATE] revealed the resident had intact cognition and was a one person assist with bathing and hygiene. Review of the discharge instructions dated 02/29/20 revealed the nurse discussed the list of prescribed medications with the resident and supplied a two-day supply of medications for the resident along with prescriptions from the physicians. Review of progress…

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 medical record review, shower schedule review, task worksheet review, observation, interviews, and review of facility policy, the facility failed to provide care to dependent residents to maintain personal hygiene. This affected two Residents (#85 and #102) out of three reviewed for personal hygiene. The current census was 134. Findings include: 1. Review of Resident #102's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, dysphagia, obesity, anxiety, muscle weakness, depression and obsessive-compulsive disorder. Review of the annual Minimum Data Set, (MDS) dated [DATE] revealed the resident had impaired cognition, and required one person assist with personal hygiene and a two person assist with bathing. Review of Resident #102's care plans dated 06/20/18 revealed a focus for self-care deficit related to impaired mobility, activity intolerance, Parkinson's and muscle weakness. Interventions included extensive assist…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to accurately code the Minimum Data Set (MDS) assessment for two (# 93 and # 43) of 44 residents reviewed during the annual survey. The total facility census was 139. Findings include: 1. Review of Resident #93's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included atrial fibrillation, encephalopaty, altered mental status, pain, chronic kidney disease, gout, and partial traumatic transphalangeal amputation of left middle finger. Review of the admission assessment, dated 12/28/18, revealed the resident had left middle finger amputation, left index finger dark area tip of finger and right index finger red and non blanchable. Review of hospital transfer orders, dated 12/28/18, revealed Resident #93 had no pressure ulcers and the resident had wounds to the finger tips. Review of the plastic surgeon note dated 12/28/18, revealed the resident had a an amputation of the distal phalanx of his left, long finger…

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

Based on observations, record review, resident interview, and staff interview, the facility failed to ensure residents were provided appropriate grooming assistance for one one (#109) of seven residents observed during phase two of the survey. The facility census was 139. Findings include: Review of Resident #109's medical records revealed an admission date of 11/06/10. Diagnoses included hypertension, hyperlipidemia, chronic obstructive pulmonary disease, idiopathic peripheral autonomic neuropathy, muscle weakness, osteoarthritis, type two diabetes mellitus, bipolar disorder, and hypothyroidism. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/10/19, revealed Resident #109 was cognitively intact, required extensive assistance with activities of daily living (ADL), and was occasionally incontinent of bladder and frequently incontinent of bowels. Observation of Resident #109 on 01/28/19 at 10:09 A.M., on 01/29/19 at 9:23 A.M., and 01/29/19 at 2:43 P.M., revealed Resident #109 had one and a half inch growth of hair underneath her chin. Resident's #109 hands 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.