Abundant Acres Care and Rehab

Inspectors wroteBased on observation, interview and record review, facility staff failed to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD) (a serious type of pneumonia(lung infection) caused by Legionella bacteria, which places all residents at risk of exposure which could lead to illness. This had the potential to affect all residents of the facility. Additionally, the facility failed to ensure staff washed or sanitized their hands between dirty and clean tasks which affected one of 12 sampled residents (Resident #12). The facility census was 44. 1. Review of the Centers for Medicare and Medicaid Services (CMS) Quality, Safety and Oversight (QSO) 17-30, dated 06/02/17 and revised on 07/06/18, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of 12 sampled residents (Resident #5 and #7) reviewed for unnecessary medications and/or their representative were informed of the risks and benefits of a physician ordered antipsychotic medication. This failure prevented the resident and/or their representative from knowing the risks and the benefits of using psychotropic medications. The facility census was 44. Review of the facility's undated Resident's Rights Policy, showed:- Residents have the right to be fully informed in writing of services, costs and changes;- Residents have the right to participate in and know their medical condition and treatment options. [...]

Inspectors wroteBased on interview and record review, the facility failed act promptly upon grievances and recommendations made by the resident council when the facility failed to document a response to the council on follow up actions. This affected all the residents serving on the resident counsel and potentially other residents of the facility. The facility census was 44. Review of the undated Resident's Rights policy, showed:- Residents have the right to receive prompt attention to concerns through staff, administration, resident councils, or the ombudsman program;- Grievances: Residents can file complaints verbally or in writing. All complaints will be investigated and responded to;- Residents have the right to receive prompt attention to concerns through staff, administration, resident councils, or the ombudsman program. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide personal funds and a final accounting within thirty days upon discharge for three residents (Resident #48, #49, and #50). This affected three of 12 residents sampled. Facility census was 44. Request for a policy covering resident funds upon discharge was not provided by the facility. 1. Review of the facility's accounts receivable aging report, dated 8/20/25, showed the following residents had money in the facility's operating account:- Resident #49 discharged on 2/13/25, with a credit balance of $5,142.00 in the Private Pay account;- Resident #48 discharged on 10/25/24, with a credit balance of $4,932.00 in the Resident Liability account;- Resident #50 discharged on 8/17/24, with a credit balance of $13,852.00 in the Private Pay account. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to file grievances in writing, the right to file grievances anonymously, access to the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number within a reasonable expected time frame for completing a review of the grievance, and the right to obtain a written decision regarding his or her grievance. This affected 8 out of the 8 residents who attended group meeting. The facility census was 44. [...]

Inspectors wroteBased on interview and record review the facility failed to provide timely access to resident electronic medical records from 8/18/25 at 10:00 A.M. through 8/19/25 at 1:45 P.M. This resulted in the surveyors being unable to timely review necessary records to conduct the survey and review of care provided to residents. The facility census was 44. Review of the facility's undated electronic medical record policy, showed:- The purpose was to establish standardized guidelines for the use, management, and protection of the facility's electronic medical record (EMR) system to ensure accuracy, confidentiality, and compliance with federal, state, and facility regulations.- Documentation will be done in real time, with use of approved terminology, abbreviations and formatting. - Access Control- Grant access levels determined by specific job role. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to protect resident rights when the facility did not inform residents in writing on how to file a complaint with the State Survey Agency and where to find the Ombudsman's contact information for two sampled residents (Residents #20 and #26) and seven of eight resident council members. The facility census was 44. Review of facility Residents' Rights policy, undated, showed no information on a process for residents to contact and file a grievance with the state of Missouri Department of Health and Senior Services. 1. Review of Resident #20's Quarterly Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 6/30/25, showed:- Resident was cognitively intact;- Diagnosis: epilepsy, traumatic brain injury, anxiety disorder, and schizophrenia. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #25) had a toilet that flushed properly. The facility census was 44. Review of the facility's undated policy for Home-Like Environment showed:- The purpose is to promote and maintain a home-like environment within the facility that enhances residents' comfort, dignity, and quality of life, while ensuring safety and regulatory compliance. - The facility will provide an environment that feels comfortable, safe, and familiar to residents. - Housekeeping and maintenance will ensure rooms are clean, safe, well-kept, and within comfortable temperatures. Review of the facility's undated policy Maintenance Repairs showed: - The facility is committed to maintaining a safe, functional, and comfortable environment for residents, staff, and visitors. [...]

Inspectors wroteBased on interview and record review, the facility failed to have documentation of one resident's (Resident #18), with serious mental illness and intellectual disability diagnosis, Level I preadmission screening resident review (PASRR) assessment (used to identify individuals with mental illness or intellectual/developmental disabilities (IDD) completed before admission to the nursing facility). The census was 44. Review of the facility PASRR policy showed the facility will complete and comply with all PASRR requirements prior to admitting any resident into the facility and will ensure timely resident reviews in the event of significant changes in condition. The facility will coordinate with the Missouri Department of Health & Senior Services (DHSS) and the Missouri Department of Mental Health (DMH) to ensure proper screenings, evaluations. and placements are carried out. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for two residents (Resident #1 and #8) that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment as well as services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The facility census was 44. Review of the facility's undated care plan policy showed the purpose of the care plan policy was to establish a standardized process for the development, implementation, review, and revision of the individualized resident care plans that ensure person-centered care, regulatory compliance, and quality outcomes. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff did not provide complete perineal care for one of 12 sampled residents (Resident #12). The facility census was 44. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff used proper techniques to reduce the possibility of accidents or injuries when staff failed to use a gait belt (safety device and mobility aid used to provide assistance during transfers, ambulation or repositioning) during a transfer for one of 12 sampled residents (Resident #12). The facility census was 44. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff maintained a medication error rate of less than five percent, when staff made two medication errors out of 25 opportunities for error, which resulted in a medication error rate of 8%. This failure affected two of 12 sampled residents, (Resident #25 and #28). The facility census was 44. Review of the facility's policy for Medication Administration, dated 5/26/25, showed:- The facility will provide pharmaceutical services, including procedures that assure accurate acquiring, receiving, dispensing, and administering of all medications to meet the needs of each resident to treat their individual medical diagnoses. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff discarded expired medications stored in the medication room, failed to ensure food was not stored with medications in the medication refrigerator, failed to ensure staff properly labeled opened, multi-dose medications with dates to indicate when they were opened and when they should be discarded, which affected two of12 sampled residents, (Resident #13 and #38) who received Lorazepam Intensol (a liquid anti-anxiety medication). Additionally, staff failed to ensure there were no loose pills in the medication cart. The facility census was 44. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure availability of staff who can provide cardiopulmonary resuscitation (CPR, any medical intervention used to restore circulatory and/or respiratory function that has ceased) when the facility did not have a full list of CPR certified staff available or copies of CPR cards in employee files. This had the potential to affect all residents who were a full code (residents who want CPR when their heart stops beating). Facility census was 43. The facility did not have a policy in place regarding staff being CPR certified or maintaining a list of staff currently on shift who are CPR certified. Review of employee files on [DATE] a 1:45 P.M., showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by Resident #1, when Resident #1 was observed by staff striking Resident #2 in the face resulting in a bruise and two facial skin tears. The facility census was 53. Review of the facility's undated Abuse and Neglect policy showed: -Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish; the infliction of physical, sexual, or emotional injury or harm; -The purpose of this policy is to ensure prevention, protection, prompt reporting and interventions in response of property, or exploitation of any facility resident. Our goal at all times will be the protection of our Residents. -All Residents have rights that are guaranteed by the federal Nursing Home Reform Law. [...]

Inspectors wroteBased on interviews and record review, the facility failed to protect the resident's right to be free from sexual abuse by Resident #1, when Resident #1 was observed by staff sitting on Resident #2's bed with his/her pants and underwear pulled down to his/her mid thigh and Resident #1's hand inside the front of Resident #2's brief. The facility's census was 56. On 1/3/25, the Administrator was notified of the past noncompliance which began on 12/25/24. Upon discovery, the facility administration immediately conducted an investigation and corrective actions were implemented. The noncompliance was corrected on 12/28/24. Review of the facility's undated Abuse and Neglect policy showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to honor the resident's right to be informed regarding care and treatment decisions when the facility failed to involve and notify one resident's (Resident #1) responsible party in the decision to change resident's medications. Medication changes included administering a medication the resident was known to have an allergy to. This affected one out of six sampled residents. The facility census was 54. Review of the facility's in-service training for staff regarding Medication Procedures and Orders, dated [DATE], showed the nurse receiving the orders, new or changes, must call the reisdent's responsible party and document the order and phone call including the name of the family member the nurse spoke with in the progress note. Review of the facility's undated Rights and Protections as a Nursing Home Resident handout, showed: [...]

Inspectors wroteBased on observation and interview, the facility staff failed to ensure all shower hoses had a backflow preventer. This affected all five shower hoses and had the potential to affect all residents. A backflow preventer keeps toxins from backing up into the facility's potable water supply. The facility census was 47. 1. Observation on 6/26/24 starting at 11:15 A.M., showed: - Two shower hoses without backflow preventer in the 400 hall shower room; - Two shower hoses without backflow preventer in the 500 hall shower room; - One shower hose without a backflow preventer in the only shower in a resident's room. During an interview on 6/26/24 at 4:30 P.M., the Maintenance Supervisor said he did not realize all shower hoses needed a backflow preventer and that none of the shower hoses had them.

Inspectors wroteBased on record review and interview, the facility failed to issue the Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN) (form Centers for Medicare and Medicaid (CMS)-10055 to each resident. The SNF ABN provides information to residents/beneficiaries so that they can decide if they wish to continue receiving the skilled services that may not be paid by Medicare and assume financial responsibility. This affected three of the 12 sampled residents (#11,#24 and #32). The facility census was 47. The facility did not provide a policy for Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN) (form Centers for Medicare and Medicaid (CMS)-10055. 1. Review of Resident #11's medical record showed: - The resident had a Notice of Medicare Non-Coverage (NOMNC) issued that showed Medicare Part A benefits were ending on 5/7/24 The resident did not have a SNF ABN in their records. [...]

Inspectors wroteBased on observation and interview the facility failed to maintain a safe, clean and comfortable homelike environment. The facility had a census of 47. The facility did not provide a policy on cleaning. Review of the facility provided, undated, daily cleaning checklist showed daily room cleaning to include: dust corners, clean walls, sweep and mop. Review of the facility provided, undated deep cleaning checklist showed cleaning to include: baseboards, fixtures, blinds, ledges dusted, above curtains free of cobwebs, etc. Observations beginning on 06/23/24 at 10:34 A.M. showed: - room [ROOM NUMBER] ceiling fan light had cobwebs and small scuffs along the lower 1/3 of the wall at the corner; -room [ROOM NUMBER] privacy curtain ceiling hooks were missing and curtain was sagging. The window curtain rod was dusty and had cobwebs, and one end was broken off; [...]

Inspectors wroteBased on record review and interview, the facility staff failed to check the Certified Nurses' Assistant (CNA) Registry for all staff to ensure they did not have a Federal Indicator (a marker given by the federal government to individuals who have committed abuse/neglect), failed to check the Family Care Safety Registry (FCSR) to ensure that persons caring for children, seniors, or physically or mentally disabled individuals can be screened for employment purposes. The law requires that every child care and elder care worker hired on or after January 1, 2001, and every personal care worker hired on or after January 1, 2002. This affected six of the six sampled staff. The facility census was 47. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADL's) received the necessary services to maintain good personal hygiene when staff failed to ensure they provided perineal care and repositioning at least every two hours. This affected two of 12 sampled residents, (Resident #25 and #29). The facility census was 47. Review of the facility's Incontinence Care Policy, dated 5/19/2024, showed: -Check the resident for incontinence at least every two hours and assist with toileting as needed; -Keep the resident's call light within reach; -Provide provide perineal care after each incontinence; -Follow the resident's toileting and incontinence care plan. Review of the facility's Resident Rights Policy, dated 5/19/24, showed in part: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of 12 sampled residents (Residents#7, #12 and #43 ) were provided an ongoing program of activities designed to meet, their individual interests and their physical, mental, and psychosocial well-being. The facility census was 47. Review of the facility policy Activity, Volunteer and Recreational Services policy dated March 2012 showed: -The Activity Director, assistants and volunteers of this facility believe that each individual has the right to achieve the maximum of his or her potential; have opportunities for social involvement on an individual or group basis; and have outlets for creative abilities offering opportunities for self development that will afford personal interest, enjoyment and satisfaction provided through an ongoing activity program. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe environment when staff failed to ensure call lights were accessible to residents. This affected two of 12 sampled residents (Resident #25 and #29. The facilty census was 47. Review of the facility's Incontinence Care Policy, dated 5/19/2024, showed: -Keep the resident's call light within reach. 1. Review of Resident #25's Quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 5/13/24 showed: - Moderate cognitive impairment; - Dependent on staff for ADL's; - Dependent on staff for transfers; - Always incontinent of bowel and bladder; - Diagnoses included Parkinson's Disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), depression and asthma. [...]

Inspectors wroteBased on interview and record review the facility failed to recognize and treat a significant weight loss for three of the 12 sampled residents (Resident #7, #10, #44). In addition, the facility failed to obtain a snack or meal when one resident (Resident #12)complained of hunger and failed to pass snacks and ice water on the Special Care Unit (SCU), affecting all 12 residents. The facility census was 47. The facility did not provide a policy on weight loss or passing ice water and snacks. 1. Review of Resident #7 Annual Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff) dated 5/10/24 showed: -Brief Interview of Mental Status (BIMS) of 2, indicated significant cognitive deficit. -No behaviors -Set up assistance of staff for meals. -Dependent on staff for Activities of Daily Living (ADL's: [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure staff provided proper respiratory care for three of 12 sampled residents (Resident #11, #27, and #151) when staff failed to effectively clean oxygen concentrator filters, properly label and date oxygen tubing, and properly fill and date humidified bottles. The facility census was 47. Review of the facility's Oxygen Policy, dated 5/19/24, showed in part: - The humidifier bottle must filled to its fullest mark with sterile water; - The charge nurse will monitor and document in the resident's record that all tubing was checked for patency and the humidifier bottle is adequately full. 1. Review of Resident #11's Significant Change Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 6/11/24 showed: - No cognitive impairment; - Dependent on staff for ADL's; [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the consultant pharmacist reviewed each resident's medication for unnecessary medications, psychoactive medication parameters, including gradual dose reductions, and drug irregularities monthly. This effected two (Resident #12, and #44) of 12 sampled residents, with the potential to effect all residents. The facility census was 47. The facility did not provide a policy on Medication Regimen Review. Review of the facility provided Resident Rights policy, dated 5/19/24 showed: -The resident has the right to a dignified existence, including freedom from chemical restraints and quality of life is maintained or improved. -The resident has the right to get proper medical care, to be informed about prescription, over the counter drugs, vitamins and supplements. 1. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Dietary Manager (DM) had the appropriate competencies and skills sets to carry to the functions of the food and nutritional services. This had the potential to affect all residents who reside in the facility. The facility census was 47. The facility did not provide a policy related to qualifications of the Dietary Manager. During an interview on 6/26/24 at 3:08 P.M., the Dietary Manager said: -He/She does not have any dietary certification; -He/She is not currently enrolled in any training or classes; During an interview on 6/26/24 at 4:52 P.M., the Administrator said: -He/She was aware the DM did not have any certifications. -It was his/her expectation that the DM have the needed certifications and training. -A consulting dietician has been hired by the facility to oversee the dietary department.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food in a form designed to meet individual needs when they did not ensure pureed foods were at an appropriate texture and consistency. The facility census was 47. The facility did not provide a policy in regards to the preparation of pureed food. Observation of the lunch meal on 6/23/24 at 12:15 P.M., showed: -The tuna casserole was very thick with a sticky consistency. The texture was not smooth as there were rice size particles. The casserole had to be chewed to be able to swallow it. -The carrots were very smooth and had a good flavor. -The mashed potatoes were very thick with a sticky consistency. The texture was smooth, with no chunks or particles. Observation of preparation of pureed food on 6/26/24 at 11:06 A.M., showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store food in a sanitary manner and failed to maintain the kitchen in a sanitary manner. This had the potential to affect all residents who received food from the facility's kitchen. The facility census was 47. Review of the facility's Nutrition Services-Department Sanitation policy, dated January 2024, showed: -Purpose: To ensure a clean and sanitary work environment; to promote and protect food safety; and to maintain compliance with Federal, State and Local regulations governing food sanitation and safety. -Department sanitation shall be maintained in a manner to support procedures for Food Safety. Staff shall be responsible for daily and weekly cleaning assignments. -Cleaning assignments shall include all equipment, cabinets, storage areas, walls, floors and refrigeration units. [...]

Inspectors wroteBased on interview and record review, the facility failed to establish an infection prevention and control program that included an antibiotic stewardship program (a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use) that included antibiotic use protocols and a system to monitor antibiotic use. The facility census was 47. The undated facility Antibiotic Stewardship policy, showed: The purpose of antibiotic stewardship is to monitor the use of antibiotics in our residents and to include training, orientation, and education of staff with emphasize on the importance of antibiotics stewardship, and inappropriate use of antibiotics. Antibiotics usage and outcome will be collected and documented using a facility-approved antibiotics surveillance tracking form. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff participated in a dementia and behavior training program prior to providing direct resident care to the 12 residents who resided on their special care unit. This effected three of the 12 sampled residents. (Resident #9, #12, and #44) The facility had a census of 47. Review of the facility provided Resident Rights policy, dated 5/19/24 showed: -The facility will support each resident's right to a dignified existence; -The facility will treat each resident with respect and dignity and care for each resident in a manner and environment that promotes his/her quality of life. Review of the facility provided, Trauma Policy, dated 5/19/24 showed: -The purpose is to address the trauma in the lives of the residents and provide necessary care to those affected by trauma; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff provided services that met professional standards of quality of care when the facility did not schedule a physician's ordered test for one resident (Resident #10), failed to schedule a physician's ordered appointment for one resident (Resident #12) and failed to monitor unnecessary medications for one resident (Resident #44), out of 12 sampled residents. The facility census was 47. The facility did not have a policy regarding professional standards of care. 1. Review of Resident #10's Quarterly MDS (Minimum Data Set) , a mandatory assessment completed by facility staff. Completed on 6/15/24 showed: -Diagnoses included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility was not administered in a manner that effectively utilized resources needed to provide essential services for residents, when the facility failed to pay essential service vendors including staffing agencies. Additionally, the facility failed to ensure the continuity of administration and that the administrator was actively involved in the supervision of the facility during an upcoming transition of ownership, causing the residents and/or families to experience stress and anxiety. This affected nine of eleven sampled residents (Residents #1, #2, #3, #4, #5, #6, #8, #10 and #11). The facility census was 47. The facility did not provide a policy regarding administration and vendor payment. The facility did not provide a policy regarding the administrator's role in the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents and families were treated in a dignified manner while the facility was transitioning to a new operator, causing the residents and families to experience stress and anxiety. This affected nine of eleven sampled residents (Residents #1, #2, #3, #4, #5, #6, #8, #10 and #11). The facility census was 47. Review of the facility policy of Promoting/Maintaining Resident Dignity, dated 2023, showed: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents and families were offered a choice of pharmacy when the primary pharmacy for the facility changed. This affected nine of 11 sampled residents (Residents #1, #2, #3, #4, #5, #6, #8, #10 and #11). The facility census was 47. Review of the facility policy of Promoting/Maintaining Resident Self-Determination, dated 2024, showed: -It is the practice of this facility to protect and promote resident rights by promoting and facilitating resident self-determination through support of resident choice. The facility will ensure that each has the opportunity to exercise his/her autonomy regarding those things that are important in his/her life such as interests and preferences. -The facility will accommodate the resident preferences to the extent possible and as agreed upon by the resident sponsor and physician. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents and families were reasonably notified of Resident Council Meetings and honoring the residents' requests of staff and family invited to meetings. This affected five of 11 sampled residents (Residents #4, #1, #2, #3, and #11). The facility census was 47. Review of the facility policy of Resident Council Meetings, dated 2024, showed: -This facility supports the rights of residents to organize and participate in resident groups, including a Resident Council. -Resident or family group is defined as a group of residents or residents' family members that meets regularly to discuss and offer suggestions about facility policies and procedures affecting residents' care, treatment, and quality of life; support each other; plan resident and family activities; [...]

Inspectors wrotePlease refer to Event ID 1GJ512 Based on interview and record review, the facility failed to provide personal funds and final accounting within 90 days upon discharge. This affected six residents (Residents #1, #2, #3, #4, #5, and #6). The facility census was 47. The facility did not provide a policy regarding refunding resident funds.

Inspectors wrotePlease refer to Event ID 1GJ512 Based on observation and interview, the facility failed to maintain a call system that was adequately equipped to allow residents to call for staff through a communication system which relayed the call directly to a staff member or to a centralized staff work area and alert in the corridor. The facility census was 47.

Inspectors wroteBased on interview and record review, the facility failed to provide personal funds and final accounting within 90 days upon discharge. This affected six residents (Residents #1, #2, #3, #4, #5, and #6). The facility census was 47. The facility did not provide a policy regarding refunding resident funds. 1. Review of the facility's aging report, dated 4/25/24, showed the following residents had money in the facility's operating account: -Resident #1 discharged on 3/8/24: with a balance of $720.00; -Resident #2 discharged on 11/8/22: with a balance of $399.00; -Resident #3 discharged on 1/16/24: with a balance of $3028.54; -Resident #4 discharged on 11/2/22: with a balance of $3321.10; -Resident #5 discharged on 1/29/24: with a balance of $1057.33; -Resident #6 discharged on 12/26/23: with a balance of $1277.23. During an interview on 4/25/24 at 1:45 P.M., the Director of Operations said: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide drinks including ice and fresh water consistent with the residents' needs and preferences. This affected four residents (Residents #2, #4, #6, and #7) out of a sample of eight residents. The facility's census was 49. Facility policy, Nutritional Management, dated 2023, showed: -Facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition. -Acceptable parameters of nutritional status refers to factors that reflect an individual's nutritional status is adequate, relative to his/her overall condition and prognosis, such as weight, food/fluid intake, and pertinent laboratory values. -Nutritional status includes both nutrition and hydration status. Facility did not provide a hydration policy. 1. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain a call system that was adequately equipped to allow residents to call for staff through a communication system which relayed the call directly to a staff member or to a centralized staff work area and alert in the corridor. The facility census was 47. The facility did not provide a policy regarding resident call light system. Observation on 4/25/24, beginning at 11:31 A.M., showed: -The call light in room [ROOM NUMBER] A on the secure unit was activated. The light above the door did not turn on and the indicator light on the call light board in the hall did not turn on. -The call light in room [ROOM NUMBER] B on the secure unit was activated. The light above the door did not turn on and the indicator light on the call light board in the hall did not turn on. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to report to Department of Health and Senior Services (DHSS) injuries of unknown origin when the facility staff became aware on 3/23/23 that one resident (Resident #1) had injuries of unknown origin. Injuries included bruising to his/her right eye, bruising to the backs of his/her right and left elbows, bruising to the top of his/her right hand, and a skin tear to his/her right outer wrist. The facility failed to report the injuries of unknown origin until 3/25/24. The facility census was 49. Review of facility policy, Abuse prevention program, investigation, dated July 2023, showed: -Reports of resident abuse, neglect, and injuries of unknown source shall be promptly and thoroughly investigation by the facility; [...]

Inspectors wroteBased on record review and interview, the facility failed to thoroughly investigate injuries of unknown origin when one resident (Resident #1) was found to have bruising on top of his/her arms, bruising to his/her right eye, and a skin tear to his/her right arm on the morning of 3/23/24 by staff. The facility failed to follow facility policy when they failed to provide documentation that all staff working were interviewed, and failed to provide complete and thorough documentation of the investigation. The facility census was 49. Review of facility policy, Abuse Prevention Program, Investigation, dated July 2023, showed: -Reports of resident abuse, neglect, and injuries of unknown source shall be promptly and thoroughly investigated by facility management. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide acceptable accommodation of needs, when they did not provide transportation to two resident's scheduled doctor appointments forcing residents to cancel and reschedule necessary medical appointments (Resident #2 and #3) The facility failed to provide acceptable accommodations of needs when facility staff woke up resident to administer medications during the night (Resident #5). The facility census was 54. Review of facility policy, transportation, dated August 2023, showed: -The community shall help arrange transportation for residents as needed; -Social services designee or person delegated by the community will help the resident as needed to obtain transportation; -Inquires concerning transportation should be refereed to social services. Review of facility policy, resident rights, dated 7/1/23, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store medications in a locked storage area to ensure medications were inaccessible to unauthorized staff and residents, when the medication cart was left unlocked and unattended. The facility census was 54. Review of facility policy, storage of medications, undated, showed: -Facility shall store all drugs and biological's in a safe, secure, and orderly manner. -Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biological's shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. Observation on 1/16/23 at 12:01 P.M. a medication cart that sat at the east end of the nurses station was observed unlocked with the lock sticking out. [...]

Inspectors wroteBased on observation, interviews and record review the facility failed to prevent an avoidable accident when the facility staff failed to properly secure a resident in the facility van causing one resident (Resident #1) to tip over in the vehicle on 12/8/23 during transportation to an appointment. Additionally, the facility failed to provide training to the activities director who drove the facility van that transported Resident #1 on 12/8/23. The facility census was 54. Review of facility policy, Accidents, undated, showed: -Facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. -Employees shall be trained and in serviced on potential accident hazards and how to identify and report accident hazards, and try to prevent avoidable accidents. [...]

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to provide the necessary care, treatment, services and equipment in accordance with professional standards to attain or maintain the highest practicable physical, mental, or psychosocial well-being for one of 13 sampled residents (Resident #42). The facility failed to ensure the resident maintained and/or improved his/her highest level of range of motion (ROM) and mobility. When he/she admitted to the facility on [DATE], he/she had active ROM (the performance of an exercise to move a joint without any assistance or effort of another person to the muscles surrounding the joint) in both ankles. Resident #42 now has muscle atrophy (the wasting or loss of muscle tissue) around ankles and feet resulting in his/her feet pointing downward, toes curling and beginning to turn in at the sides. The facility's census was 50. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their water management policy and procedures to reduce the risk of growth and spread of Legionella (bacteria that causes Legionnaires' disease, a serious type of pneumonia and did not review it annually. The facility also failed to ensure facility staff were informed on the facility's Water Management Plan. The facility failed to monitor the health of the employees when staff did not administer the required two-step tuberculosis (TB - a communicable disease that affects the lungs characterized by fever, cough, and difficulty in breathing) screening test upon hire as per policy for three of 10 sampled employees. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to maintain a call system that was adequately equipped to allow residents to call for staff through a communication system which relayed the call directly to a staff member or to a centralized and staff work area. This directly affected one sampled resident (Resident #1) and had the potential to affect all residents. The facility census was 48. Review of the facility's policy Call Lights: Accessibility and Timely Response, showed: -The purpose of this policy is to provide guidance to the facility to be adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance; -Call lights will directly relay to a staff member or centralized location to ensure appropriate response. 1. [...]

Inspectors wroteBased on record review and interview, the facility failed to check the Missouri Department of Health and Senior Services (DHSS) Employee Disqualification List (EDL), a list maintained by DHSS of individuals who have been determined to have abused or neglected a resident, patient, client or consumer, misappropriated funds or property belonging to a resident, patient, client, or consumer, for 10 of 10 sampled employees prior to them having contact with any resident. The facility census was 50. Review of the facility's undated Abuse, Neglect and Misappropriation policy showed: - The facility strictly prohibits abuse, neglect and misappropriation of residents and their property; - Screening: all employees will complete a pre-screening process to ensure there is not a history of abuse or neglect and there are no issues barring them from employment; - All staff must complete the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff provided written notice of transfer or discharge to residents or their responsible party and the reasons for the transfer in writing in a language they understood. This affected three of 13 sampled residents, (Resident #5, #23 and #250). The facility census was 50. Review of the facility's undated transfer and discharge policy, showed in part: - It is the policy of this facility to permit each resident to remain in the facility, and not initiate transfer or discharge for the resident from the facility, except in limited circumstances; - Once admitted , the resident has the right to remain at the facility unless their transfer or discharge meets on the following specified exemptions: the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure they provided care and treatments in accordance with professional standards of quality when staff failed to have a physician's order to check blood sugars, for one of 13 sampled residents (Resident #23), failed to have a physician's order to flush a peg tube (a tube placed in the stomach to provide a route to deliver nutrition, fluids and medication), which affected one sampled resident (Resident #16) and failed to allow fingertips to dry before obtaining blood sugars for five sampled residents (Residents #1, #2, #20, #23 and #24). The facility census was 50. The facility did not provide a policy for following physician's orders, administration of medications through the peg tube, or obtaining blood sugars. Review of the website, www.shieldhealthcare.com showed: [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff did not provide complete perineal care which affected two of 13 sampled residents (Resident #5 and #18) and failed to ensure they provided showers for three sampled residents (Residents #1, #16 and #32). The facility census was 50. Review of the facility's undated policy for perineal care, showed, in part: - It is the practice of the facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown; - Perform hand hygiene and don gloves; [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure staff administered medications with a medication rate of less than five percent. Facility staff made 12 medication errors out of 25 opportunities for error, with a medication error rate of 48%, which affected five of 13 sampled residents, (Residents #3, #12, #16, #23, and #42). The facility census was 50. Review of the facility's undated policy for medication administration showed in part: - Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection; - Keep medication cart clean, organized, and stocked with adequate supplies; - Cover and date fluids and food; [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure they developed and implemented a comprehensive person-centered plan of care which included measurable objectives and timeframes to meet each resident's medical, nursing, mental and psychosocial needs for two of 13 sampled residents (Resident #1 and #9). The facility census was 50. The facility did not provide a policy for care plans. 1. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/28/22, showed: - Cognitive skills intact; - Required extensive assistance of two staff for bed mobility; - Limited assistance of one staff for transfers, dressing ant toilet use; [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure staff used proper techniques to reduce the possibility of accidents or injuries when transferring two of 13 sampled residents (Resident #5 and #18) during the use of a mechanical lift. The facility census was 50. Review of the facility's undated policy for safe resident handling/transfers showed in part: - It is the policy of the facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines; - Mechanical lifting equipment or other approved transferring aids will be used based on the resident's needs to prevent manual lifting except in medical emergencies; [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure staff discarded expired stock medication stored in the medication room, failed to ensure there was no food in the medication refrigerator, failed to ensure opened insulin pens and vials were dated and failed to ensure there were no loose pills in the medication cart. The facility census was 50. Review of the facility's undated policy storage of medication requiring refrigeration showed in part: - It is the policy of the facility to assure proper and safe storage of medications requiring refrigeration and to prevent the potential alteration of medication by exposure to improper temperature controls; [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure staff stored food in a sanitary manner and failed to maintain the kitchen in a sanitary manner. This has the potential to affect all residents residing in the facility. The facility census was 50. Review of the facility's undated Food Safety Requirements policy showed: - It is the policy of this facility to ensure food will be stored, prepared, distributed and served in accordance with professional standards for food service safety; - Storage of food shall be in a manner that helps to prevent deterioration or contamination of the food, including growth of microorganisms; - Staff shall maintain safe food storage practices by labeling, dating and monitoring frozen and refrigerated foods; - Staff shall ensure foods are covered or in tight containers. Observation of the kitchen on 1/16/23 at 9:08 A.M., showed: [...]