Stonebridge Maryland Heights

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident was provided with adequate supervision and staff oversight when the resident wandered outside and was brought back to their secured housing unit after approximately five to ten minutes of being outside unsupervised (Resident #1). The resident knocked on the door of a different housing unit and was brought back to their unit by a Certified Nursing Assistant (CNA). The sample was 9. The census was 136. The Administrator was notified on 3/26/26 of the past non-compliance. The facility in-serviced nursing staff on alarms and monitoring exits when alarms by the doors are making noise. They were in-serviced on identifying residents at risk of elopement and those who having exit seeking behavior. [...]

Inspectors wroteBased on interview and record review, the facility failed to immediately notify the resident's physician when there was a significant change in the resident's physical status for one resident (Resident #1), per facility policy when the resident experienced a hypoglycemic episode and became unresponsive. The resident experienced a second hypoglycemic episode on the following shift, required life saving measures, and was sent out to the hospital urgently. The sample size was 8. The facility census was 141. Review of the facility's Change in a Resident's Condition or Status policy, dated [DATE], showed the nurse will notify the resident's attending physician or physician on call when there has been a significant change in the resident's physical/emotional/mental condition. [...]

Inspectors wroteBased on interview and record review, the facility failed to establish a system of records for all controlled drugs with sufficient detail to enable an accurate reconciliation, for four out of six medication carts reviewed. This had the potential to affect all residents with orders for controlled substances. The census was 150. Review of the facility's Controlled Substances policy, revised 2016, showed:-Policy Statement: [...]

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards when staff failed to administer and document medications as ordered by the physician for six of seven sampled residents (Residents #6, #2, #4, #5, #3 and #1). The census was 150. Review of the facility's Administering Medications policy, revised 2012, showed:-Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed;-Policy Interpretation and Implementation: -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 will supervise and direct all nursing personnel who administer medications and/or have related functions; -Medications must be administered in accordance with the orders, including any required time frame; [...]

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to ensure food stored in the main kitchen was labeled, dated, and disposed upon expiration. These failures had the potential to increase the prevalence and spread of foodborne illnesses for 140 of the 142 facility residents.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to provide knives with meals for two residents (Resident (R) 56 and R107) and staff was observed to stand while feeding (R) 22. These failures to promote dignity in dining had the potential to affect the 38 residents in the dining room.

Inspectors wroteBased on interview and record review, the facility failed to ensure six of seven (Residents (R)121, R5, R65, R107, R7, and R136) reviewed for care planning of 33 sampled residents was afforded the right to participate in their care planning process. This failure placed the resident at risk of not being aware of the goals and outcomes of their care.

Inspectors wroteBased on interview and record review, the facility failed to ensure third party liability (TPL) forms were completed within 30 days for the final accounting for residents who expired. This affected 12 residents who expired and had money in their accounts (Residents #301, #302, #303, #304, #305, #306, #307, #308, #309, #310, #311 and #312). The financial sample was 12. The census was 146. Review of the facility's Resident Trust Fund Account Policy and Procedures, revised [DATE], showed the following: -Policy: It is the policy of the facility to manage personal funds of our residents, upon request and written authorization of the resident or legal representative. Funds will be managed in accordance with Federal and State Regulations; -Procedure: Upon discharge of a resident with a balance in the Resident Trust Fund, the facility will provide a final accounting within thirty days. [...]

Inspectors wroteBased on record review, staff interviews, review of Centers for Medicare and Medicaid Services (CMS) website, and policy review, the facility failed to issue the appropriate notice for termination of Medicare part A benefits for three (Resident (R)92, R1, and R49) residents reviewed for beneficiary notification out of a total sample of 33 residents. These failures had the potential to result in a lack of understanding of appeal rights and/or the termination of the current level of care against the residents'/representative's wishes.

Inspectors wroteBased on interviews and record review, the facility failed to provide an ongoing program of resident preferred activities three residents (Resident (R)27, R93, and R137) reviewed for activities in sample size of 33 residents. This failure placed R27, R93 and R137 at risk for increased feelings of isolation, depression, helplessness, and boredom.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent. A total of five errors occurred out of 33 opportunities for error due to residents not receiving their medications that were ordered and one medication not being the ordered strength, for one resident (Resident (R)50) of five residents observed for medication administration. The facility medication error rate was 15.15%. This failure had the potential to affect the accurate dosing of medication administered to the residents.

Inspectors wroteBased on observations, interview, and facility policy review, the facility failed to ensure menus were followed and food preferences were honored for four residents (Resident (R)5, R65, R56, and R107) reviewed out of a total sample of 33 residents. The failure placed 140 of the 142 residents in the facility at risk of nutritional problems and dissatisfaction with their meals.

Inspectors wroteBased on observation, interview, and review of the Dietary Manager's (DM) job description, the facility failed to provide palatable meals for four of four residents (Residents (R) 56, R9, R54, and R107) who complained their meals were not appetizing out of a total sample of 33 residents. This failure increased the risk of residents not being satisfied with their meals.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to monitor the use of antibiotics for three of three residents (Resident (R)86, R81, and R102) reviewed for antibiotic stewardship of a total sample of 33 residents.

Inspectors wroteBased on observation, record review, staff interview, and policy review, the facility failed to ensure that a resident was assessed for self-administration of medications prior to medications being left at the bedside for one of one resident (Resident (R)68) reviewed for self-administration out of a total sample of 33 residents. This failure had the potential for the medication errors to be made.

Inspectors wroteBased on staff interview and record review, the facility failed to accurately code the Minimum Data Set (MDS) for one of 35 sampled residents (Resident (R)121). This failure reflected R121 was receiving care or treatments that was inaccurate.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the Pre-admission Screen and Resident Review (PASARR) Level I screen was completed prior to admission for one of four residents (Resident(R) 112) reviewed for PASARR out of a total sample of 33 residents. This created a potential failure to identify what specialized or rehabilitative services the resident needed and whether placement in the facility was appropriate prior to admission.

Inspectors wroteBased on observation, record review, and interview, the facility failed to follow infection control guidelines during a wound care observation for one of three residents (Resident (R)1) reviewed for wounds out of 33 sampled residents. This failure had the potential for infections to be spread to vulnerable residents in a high-risk population.

Inspectors wroteBased on interview and record review the facility failed to notify one resident's representative (Resident #1) of a newly acquired skin condition. The sample size was five. The census was 142. The Administrator was notified on 10/23/24, of the past non-compliance. The facility in-serviced nursing staff regarding notification and documentation of the notification to residents' responsible parties, regarding any new skin conditions or refusals of care concerning skin treatments. The deficiency was corrected on 9/26/24. Review of the facility's Acute Condition Changes policy, revised December, 2015, showed physicians and resident representatives shall be contacted in the case of an acute condition change. Review of the Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/7/24, showed: -Severe cognitive impairment; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one resident (Resident #1) with a pressure wound (skin or soft tissue injury that develops with prolonged periods of pressure over specific areas of the body) received the necessary treatments and services to promote healing by not thoroughly documenting skin assessments and wound progress and descriptions. The sample size was five. The census was 142. The Administrator was notified on 10/23/24, of the past non-compliance. The facility in-serviced nursing staff regarding completion and documentation of skin assessments, assessments and documentation of new wounds and the progress of the wounds, and the protocols to follow if wound healing is not progressing. The deficiency was corrected on 9/26/24. Review of the facility's Pressure Ulcer and Skin Breakdown policy, revised March, 2020, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide residents food that is palatable and at a safe and appetizing temperature for eight of 29 sampled residents (Residents #36, #123, #66, #122, #102, #47, #136 and #58) and for the residents who received hall trays. The census was 145. 1. Review of the facility's Resident Nutrition Services policy, revised July 2017, showed the following: -Policy: Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident; -Policy Interpretation and Implementation: The multidisciplinary staff including nursing staff, the attending physician and the dietitian will assess each resident's nutritional needs, food likes, dislikes and eating habits. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide residents with a homelike environment. The facility failed to keep soiled linen carts out of resident rooms. The facility also failed to ensure main entrances, dining room, hallways, and resident rooms were free of odors. The census was 145. Review of the facility's routine cleaning and disinfection policy, revised October 2022, showed: -Policy statement: It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible; -Routine cleaning and disinfection of frequently touched or visibly soiled surfaces will be performed in common areas, resident rooms, and at the time of discharge; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an ongoing activity program based on resident preferences, to support residents in their choice of activities and meet the needs of the residents. The facility failed to provide adequate organized activities in the evenings and on the weekends. The resident council representatives reported activities to be insufficient. In addition, residents observed and interviewed reported concerns with the activity program (Residents #36, #47, #102, #135, #108, #64 and #58). The census was 145. Review of the facility's Activity Evaluation policy, revised June 2018, showed: -Policy Statement: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure side rails were accurately assessed as a necessary device prior to installation and use. The facility also failed to obtain physician's orders for the use of side rails and failed to document usage in the residents' care plan for seven of 29 sampled residents (Residents #102, #27, #73, #45, #58, #84 and #59). The census was 145. Review of the facility's Proper Use of Side Rails policy, dated September 2022, showed: -Policy Statement: It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. If bed rails are used, the facility ensures correct installation, use, and maintenance of the rails; -Definitions; [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure that medications kept in facility medication rooms and on medication carts were within the date of expiration and failed to ensure wound dressings were disposed of when expired. The facility census was 145. Review of the facility's Storage of Medications policy, revised in April 2007 and in use at the time of survey, showed: -The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed; -Facility nursing staff are responsible for maintaining medications stored in facility medication rooms and on facility medication carts. 2. Observation of the 200 hall medication room on 9/12/23 at 10:25 A.M., showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to have corresponding recipes for meals served, to ensure residents were served meals in accordance with physician orders and provide an alternate menu (Residents #36, #92 and #58). The sample was 29. The census was 145. 1. Review of the lunch menu for 9/14/23, showed the following: -Resident choice meal with 3 ounces of protein; -Residents voted to have fried rice and shrimp for a meal. Observation of the lunch meal prep on 9/14/23, showed the following: -At 10:11 A.M., the Dietary Manager scooped various amounts of rice, scrambled eggs and meat with no precise measurements. After the food was fried, she placed the fried rice mixture into a pot for the steam table. -No recipe was followed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared under sanitary conditions by failing to wear beard nets and failing to ensure proper hand washing/glove techniques were followed. The Sample was 29. The Census was 145. 1. Review of the facility's Preventing Foodborne Illness: Employee Hygiene and Sanitary Practices policy, dated October 2008, showed the following: -Policy: Food Services employees shall follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness; -Procedure: All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents; -Employees must wash their hands: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had complete, accurate, and individualized care plans to address the specific needs of four residents (Residents #68, #102, #36 and #27). The sample was 29. The census was 145. Review of the facility's Comprehensive Care Plan policy, revised October 2022, showed: -Policy Statement: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment; -Policy Explanation and Compliance Guidelines included: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to adequately provide assistance to promote good nutrition and maintain acceptable parameters of nutritional status to provide one resident (Resident #28), with significant weight loss, nutritional needs as ordered. The sample size was 29. The census was 145. Review of the facility's Resident Nutrition Services policy, dated July 2017, showed: -Policy Statement: Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident; -Policy Interpretation and Implementation: The multidisciplinary staff, including nursing staff, the Attending Physician and Dietitian will assess each resident's nutritional needs, food likes, dislikes and eating habits: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medical records were accurately documented in accordance with acceptable professional standards of practice when staff documented nutritional health shakes as administered for one resident (Resident #28), eye drops as administered for one resident (Resident #47) and Juven (nutritional powder used for wound healing) as administered for one resident (Resident #12), when the health shakes, eye drops, and Juven were not provided. The census was 145. Review of the facility's Charting and Documentation policy, revised July 2017, showed: -Policy statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide dignity to residents by failing to provide meals to all residents at a table at the same time, and treat residents in a respectful manner during meal service. Furthermore, the facility failed to respect residents' privacy when a staff member walked into residents' rooms while talking on a cell phone. The sample was 35 and the census was 185. 1. Observation on 12/18/19 in the main dining room during the dinner meal, showed the following: -At 4:45 P.M., three residents sat at a table, two of the residents had their food and were almost done eating. One of the residents sat at the same table with no food in front of him/her. At 5:04 P.M., the third resident received his/her tray; -At 4:50 P.M. two residents sat at a table. One of the residents ate and the other one did not have a tray. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents' environment was maintained in a clean, orderly and comfortable manner regarding floors, walls, resident equipment including tube feeding stands, cubicle curtains, call lights and water dispensers. This affected nine sampled resident rooms, the dining rooms, water dispensers for residents and the shower/bathrooms. The sample was 35 and the census was 185. 1. Observation of Resident #121's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/5/19, showed the resident was totally dependent on staff for activities of daily living (ADLs). Review of the resident's current physician's orders, showed the resident received tube feedings every four hours. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain physician's orders for dialysis (process for removal of waste and excess water from the blood due to kidney failure) treatment and care, obtain daily weights, administer medication on dialysis days as ordered, clarify physician's order for an indwelling urinary catheter, apply elastic support stockings, follow physician's orders for correct administration of oxygen and obtain physician's order for oxygen therapy, for five sampled residents (Residents #322, #112, #49, #34 and #61). The sample was 35. The census was 185. 1. Review of Resident #322's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/8/19, showed the following: -No cognitive impairment; -Received dialysis; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that two residents received treatment and care in accordance with professional standards of practice by not effectively communicating a hospice resident's (Resident #83) significant weight loss to his/her guardian and document interventions in place prior to a resident (Resident #96) being sent out to the hospital with a change in condition. The sample was 35. The census was 185. 1. Review of Resident #83's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/22/19, showed the following: -admitted to the facility on [DATE] on hospice care; -Moderately impaired cognitive skills for daily decision making; -Total dependence on staff for personal hygiene, eating and toileting; -Upper and lower extremity impairment; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide restorative therapy services for residents who had physician orders to provide these services. This affected five of eight sampled residents who had order for restorative services (Resident's #49, #121, #166, #96 and #34). The sample was 35. The census was 185. 1. Review of Resident #49's physician progress notes, showed the following: -Current diagnoses including dementia, coronary obstructive pulmonary disease (COPD, a lung disease), high blood pressure, psychosis, difficulty in walking, generalized muscle weakness, other abnormalities of gait and mobility, schizoaffective disorder, bipolar disorder and cataracts; -On 7/24/19 at 7:44 A.M., resident fell coming out of room. Complained of falling in small space between the bed and dresser. He/she hit his/her knee on the floor and sustained a skin tear; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to protect one resident (Resident #34) from injury during a transfer, failed to follow their policy and the manufacturer's recommendations during two of two resident (Resident's #155 and #101) transfers with a Hoyer lift (mechanical lift used to transfer a resident from one surface to another), failed to follow their policy after a resident's fall (Resident #49) and failed to prevent access to razors and chemicals in three of four central bathrooms, leaving them available to all residents who were able to move freely around the facility. The sample size was 35. The census was 185. 1. Review of Resident #34's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/2/19, showed the following: -No cognitive impairment; -Unable to ambulate; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure certified nurse aides (CNAs) received the required 12 hours of training and have a system to track the hours for four of four sampled CNAs reviewed who worked at the facility for over a year. The census was 185. 1. Review of CNA K's training record, showed the following: -Date of hire (DOH), 4/3/18; -Total hours of training completed for the last full year of employment, 8 hours. 2. Review of CNA S's training record, showed the following: -DOH, 7/19/11; -Total hours of training completed for the last full year of employment, 8.75 hours. 3. Review of CNA V's training record, showed the following: -DOH, 10/12/14; -Total hours of training completed for the last full year of employment, 6.25 hours. 4. Review of CNA W's training record, showed the following: -DOH, 3/2/18; [...]

Inspectors wroteBased on interview and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail, to ensure an accurate reconciliation of controlled substances. The facility failed to properly document narcotic counts for the controlled substances for seven of nine medication carts. The census was 185. 1. Review of the Certified Medication Technician (CMT) narcotic count sheet, dated 12/1/19 through 12/18/19, on the 200 East Hall, showed the following: -No signature by the off-going CMT, a total of 26 shifts; -No signature by the on-coming CMT, a total of 28 shifts; -Total narcotic drug cards not documented as counted, a total of 15 shifts. 2. Review of the nurses narcotic count sheet, dated 12/1/19 through 12/18/19, on the 100 [NAME] Hall, showed the following: -No signature by the off-going nurse, a total of 16 shifts; [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure food items were labeled, dated and sealed appropriately; failed to maintain clean vents in the Manor dining rooms; failed to ensure the kitchen floors were maintained free of debris and dirt build up and failed to ensure dietary staff used safe food handling techniques during meal service. In addition, staff dried clean dishware on a rusty drying rack. The census was 185. 1. Observations of the main kitchen on 12/15/19 at 6:33 A.M., showed the following: -Signs on the exterior of the reach in refrigerators, showed Label and date everything before it goes in refrigerator; -In the reach in refrigerator near the coffee station, a tray with at least 40, two ounce (oz) clear plastic containers of salad dressing with no dates; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to follow acceptable infection control practices to prevent the spread of infection during perineal (area between the thighs, extending from the pubic bone to the tail bone) care by not handwashing and touching a resident with soiled gloves (Residents #105, #110 and #54), allowing a catheter bag to rest on the floor with urine unable to drain from looped tubing (Resident #88), not cleansing the glucometer (device used to check blood sugar) with an approved disinfectant before and after use (Resident #272), placing the glucometer on an unclean surface and transporting it under his/her axilla (arm pit) (Resident #34) and allowing a nasal cannula (a device for delivering oxygen by way of two small tubes that are inserted into the nares) to rest on a bed and seat of a recliner (Resident #61). The sample was 35. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide a final account of resident trust fund balances within 30 days to the individual or probate jurisdiction administering the resident's estate for one expired resident (Resident #22) and for two discharged residents (Residents #25 and #38). The facility census was 185. 1. Record review of the facility maintained Discharge Report dated [DATE], showed Resident #22 expired on [DATE]. Record review of the facility maintained Resident Fund Petty Cash Box, for the period [DATE] through [DATE], showed an envelope with Resident #22's name written on it. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the Department of Health and Senior Services (DHSS) immediately after a resident alleged his/her leg was fractured during an improper transfer (Resident #34) and after the discovery of an injury of unknown origin to a non-verbal resident (Resident #83). The sample size was 35. The census was 185. 1. Review of Resident #34's quarterly Minimum Data Set (MDS), dated [DATE], showed the following: -No cognitive impairment; -Unable to ambulate; -Limited assistance required for transfers, bed mobility, dressing, toileting and personal hygiene; -Impairment to upper extremity on one side and no impairment to lower extremities; -Occasional pain at a level of four on a zero to 10 scale; -Received non scheduled pain medication; -No falls; -Diagnoses included heart failure, kidney failure, chronic lung disease and anxiety. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to conduct a complete and thorough investigation of a fracture to one resident's leg (Resident #34) and an injury of unknown cause to a nonverbal resident (Resident #83) and failed to submit their investigation in the required time frame to the Department of Health and Senior Services (DHSS). The sample size was 35. The census was 185. 1. Review of Resident #34's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/2/19, showed the following: -No cognitive impairment; -Unable to ambulate; -Limited assistance required for transfers, bed mobility, dressing, toileting and personal hygiene; -Impairment to upper extremity on one side and no impairment to lower extremities; -Occasional pain at a level of four on a zero to 10 scale; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to notify the physician and family, did not attempt new interventions and did not monitor consumption for one resident with a significant weight loss of 10.52% over three months (Resident #155). Furthermore, the facility failed to adequately monitor and implement additional meal supplements for one resident with significant weight loss of 9.63% in three months and a significant weight loss of 15.23% in six months (Resident #96). The sample was 35 and the census was 185. 1. Review of Resident #155's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/27/19, showed the following: -Severe cognitive impairment; -Dependent on staff for transfers and personal hygiene; -Extensive assistance required for bed mobility, dressing and toileting; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the most recent survey results in a place readily accessible to residents, family members and the public. The facility also failed to post notices in a prominent location of the availability of the reports in the Manors (four separate buildings). Furthermore, the facility failed to maintain reports from complaint investigations made during the three preceding years for review upon request. The census was 185. Observations on all days of the survey on 12/15/19, 12/17/19 through 12/20/19 and 12/23/19, showed the following: -A sign in the front lobby of the main building showed the survey results were available at the front desk; -No postings regarding the availability of the most recent survey results or the prior three years in Magnolia, Aspen, Cypress or [NAME] Manors. [...]

Inspectors wroteBased on interview and record review, the facility failed to issue a written notice for transfer/discharge to the resident and/or resident's representative, when the resident was transferred to the hospital for various medical reasons for eight residents (Residents #61, #5, #82, #59, #91, #166, #75 and #96). The sample was 35. The census was 185. 1. Review of Resident #61's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, admission and discharge assessments, showed the following: -Original admission date to the facility 7/27/18; -discharged to the hospital 9/24/19; -readmission to the facility 9/29/19; -discharged to the hospital 10/10/19; -readmission to the facility 10/19/19; -No documentation a written transfer/discharge notice was provided to the resident and/or their representative at the time of the transfers to the hospital. [...]