Waters of Chesterfield Skilled Nursing Facility

In the surveyor’s words

From the most serious findings on record at Waters of Chesterfield Skilled Nursing Facility, in the surveyor’s own words.

• Immediate jeopardy, isolatedF686Jun 17, 2021

  Based on interview and record review the facility failed to implement interventions, failed to prevent a pressure ulcer, and failed to prevent the worsening of a pressure ulcer for a resident with a history of skin alteration, for 1 of 3 residents reviewed for pressure ulcer (Resident B). This deficient practice resulted in the resident wound first being identified as unstageable and then continued to worsen resulting in bone exposure and [CONDITION(S)]. The immediate jeopardy began on 4/21/2021 when Resident B developed an unstageable pressure ulcer. The Administrator was notified of the immediate jeopardy on 6/17/2021 at 5:54 p.m. […]

• No harm, potential for more than minimal, widespreadF812Jan 13, 2025

  Based on observation, interview and record review, the facility failed to ensure food was prepared and served under safe and sanitary conditions. This deficient practice had the potential to impact 39 of 39 facility residents. Finding include: During a lunch meal service observation on 1/9/25 from 12:00 p.m. to 12:40 p.m. the following concerns regarding food handling, food distribution, hand washing, glove use, and prevention of cross contamination were made: The Acting Dietary Manager (ADM) was wearing gloves on both hands. He began meal services, touching meal tickets, meal trays, bowls, counter tops, lids, utensils, napkin wrapped silverware, and the food contact surface of plates with his gloved hands. […]

• No harm, potential for more than minimal, patternF656Jan 22, 2024

  Based on interview and record review, the facility failed to ensure care plans had measurable goals and individualized approaches for 4 of 14 residents reviewed for care plan development (Residents 44, 45, 4, and 19) Findings include: 1. Resident 44's clinical record was reviewed on 1/18/24 at 11:15 a.m. Current diagnoses included anxiety disorder, insomnia, hypertension, malaise, and acquired absence of right leg above the knee. An 11/2/23, quarterly, Minimum Data Set (MDS) assessment indicated the resident had no cognitive limitation, understood others and was understood by others, and displayed no maladaptive behaviors during the assessment period. The resident had a current, 11/2/23, care plan problem/need regarding insomnia. […]

• No harm, potential for more than minimal, patternF657Jan 22, 2024

  Based on interview and record review, the facility failed to review and revise care plans for 1 of 14 resident reviewed for care plan revision (Resident 4). Findings include: Resident 4's clinical record was reviewed on 1/17/24 at 11:33 a.m. Current diagnosis included Alzheimer's disease, major depressive disorder, anxiety disorder, and unspecified psychosis. A 12/16/23, quarterly, Minimum Data Set (MDS) assessment indicated the resident had mild cognitive limitations, understood others and was understood by others, had moderate self-reported depression, received antipsychotic medication, antianxiety medication, and antidepressant medication daily, and displayed no maladaptive medications during the assessment period. […]

• No harm, potential for more than minimal, patternF745Jan 22, 2024

  Based on observation, interview, and record review, the facility failed to offer medically related social services to residents with a diagnosis of a major mental illness in relation to behavior monitoring, behavior management, updating care plans, and provision of personalized care for mental and behavioral health for 4 of 4 residents reviewed for provision of medically related social services (Residents 44, 45, 4 and 19) Findings include: 1. During a resident group interview on 1/17/24 at 10:30 a.m., Resident 44 indicated he suffered from insomnia and liked to sleep whenever he can. Staff woke him up for showers and such. […]