2014-10-01
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Inspection Results
Recertification/Complaint Investigation/State Licensure - (25-AUG-11)
Facility failed to meet the following Requirement(s):Date CorrectedLevel of HarmResidents Affected
Upon written authorization of a resident, the facility must hold, safeguard, manage, and account for the personal funds of the resident deposited with the facility, as specified in paragraphs (c)(3)-(8) of this section. The facility must deposit any resident's personal funds in excess of $50 in an interest bearing account (or accounts) that is separate from any of the facility's operating accounts, and that credits all interest earned on resident's funds to that account. (In pooled accounts, there must be a separate accounting for each resident's share.) The facility must maintain a resident's personal funds that do not exceed $50 in a non-interest bearing account, interest-bearing account, or petty cash fund. The facility must establish and maintain a system that assures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf. The system must preclude any commingling of resident funds with facility funds or with the funds of any person other than another resident. The individual financial record must be available through quarterly statements and on request to the resident or his or her legal representative. The facility must notify each resident that receives Medicaid benefits when the amount in the resident's account reaches $200 less than the SSI resource limit for one person, specified in section 1611(a)(3)(B) of the Act; and that, if the amount in the account, in addition to the value of the resident's other nonexempt resources, reaches the SSI resource limit for one person, the resident may lose eligibility for Medicaid or SSI. 07-OCT-11No actual Harm with potential for More than minimal harm that is not immediate jeopardyFew
The resident has the right to personal privacy and confidentiality of his or her personal and clinical records. Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. Except as provided in paragraph (e)(3) of this section, the resident may approve or refuse the release of personal and clinical records to any individual outside the facility. The resident's right to refuse release of personal and clinical records does not apply when the resident is transferred to another health care institution; or record release is required by law. The facility must keep confidential all information contained in the resident's records, regardless of the form or storage methods, except when release is required by transfer to another healthcare institution; law; third party payment contract; or the resident. 07-OCT-11No actual Harm with potential for More than minimal harm that is not immediate jeopardyFew
The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. 07-OCT-11No actual Harm with potential for More than minimal harm that is not immediate jeopardyFew
A facility must use the results of the assessment to develop, review and revise the resident's comprehensive plan of care. The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.25; and any services that would otherwise be required under 483.25 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(b)(4). 07-OCT-11No actual Harm with potential for More than minimal harm that is not immediate jeopardyFew
The services provided or arranged by the facility must meet professional standards of quality. 07-OCT-11No actual Harm with potential for More than minimal harm that is not immediate jeopardyFew
A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. 07-OCT-11No actual Harm with potential for More than minimal harm that is not immediate jeopardyFew
The facility must employ sufficient support personnel competent to carry out the functions of the dietary service. 07-OCT-11No actual Harm with potential for More than minimal harm that is not immediate jeopardyMany
Menus must meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences; be prepared in advance; and be followed. 07-OCT-11No actual Harm with potential for More than minimal harm that is not immediate jeopardyMany
Therapeutic diets must be prescribed by the attending physician. 07-OCT-11No actual Harm with potential for More than minimal harm that is not immediate jeopardyFew
The facility must establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. (a) Infection Control Program The facility must establish an Infection Control Program under which it - (1) Investigates, controls, and prevents infections in the facility; (2) Decides what procedures, such as isolation, should be applied to an individual resident; and (3) Maintains a record of incidents and corrective actions related to infections. (b) Preventing Spread of Infection (1) When the Infection Control Program determines that a resident needs isolation to prevent the spread of infection, the facility must isolate the resident. (2) The facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease. (3) The facility must require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. (c) Linens Personnel must handle, store, process and transport linens so as to prevent the spread of infection. 07-OCT-11No actual Harm with potential for More than minimal harm that is not immediate jeopardyFew
Each resident shall receive personal attention and nursing care in accordance with his/her condition and consistent with current acceptable nursing practice. I/II 07-OCT-11Refer to definitions of Class I, I/II, II, II/III, III deficiencies
Residents shall be cared for by using acceptable infection control procedures to prevent the spread of infection. The facility shall make a report to the division within seven (7) days if a resident is diagnosed as having a communicable disease, as determined by the Missouri Department of Health and listed in the Code of State Regulations pertaining to communicable diseases, specifically 19 CSR 20-20.020, as amended. I/II 07-OCT-11Refer to definitions of Class I, I/II, II, II/III, III deficiencies
Each resident shall be served nutritious food, properly prepared and appropriately seasoned, taking into consideration resident food preferences, to provide an adequate diet in accordance with the physician's order and as recommended by the National Research Council. Nutritional needs of residents shall be met and shall be based on the individual's circumstances, medical condition and goals of treatment as determined and justified by the physician. A qualified professional, such as a dietitian or registered nurse, shall regularly assess these needs and shall keep the physician informed of the nutritional status of the resident. I/II 07-OCT-11Refer to definitions of Class I, I/II, II, II/III, III deficiencies
There shall be sufficient personnel properly trained in their duties to assure adequate preparation and serving of food. II 07-OCT-11Refer to definitions of Class I, I/II, II, II/III, III deficiencies
A file of standardized recipes shall be used. III 07-OCT-11Refer to definitions of Class I, I/II, II, II/III, III deficiencies
(29) Each resident shall be treated with consideration, respect, and full recognition of his or her dignity and individuality, including privacy in treatment and care of his or her personal needs. All persons, other than the attending physician, the facility personnel necessary for any treatment or personal care, or the department or Department of Mental Health staff, as appropriate, shall be excluded from observing the resident during any time of examination, treatment, or care unless consent has been given by the resident. II/III 07-OCT-11Refer to definitions of Class I, I/II, II, II/III, III deficiencies