Alpine Breeze Health and Wellness

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure adequate supervision and implement effective measures to prevent resident elopement for one sampled resident (Resident #1) of 8 sampled residents who resided on the facility's secured memory care unit. On 4/29/26, the main door out of the memory care unit did not fully latch after use. As a result, the resident was able to exit the secured unit unsupervised, access the facility elevator and make his/her way out of the facility through a door where the alarm had been temporarily disabled, without staff awareness, and was later located by law enforcement at a local barbershop without injury. The facility census was 146 residents. The Administrator was notified on 5/7/26 of the past noncompliance which began on 4/29/26. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of ten sampled residents, Resident #1 was free from abuse, when on 1/27/26 at approximately 2:23 A.M. Resident #2 struck Resident #1 on the face while Resident #1 was sleeping in bed, due to an auditory hallucination. As a result of the altercation, Resident #1 sustained a laceration to the inner lip and minor swelling to his/her left eye. The facility census was 142 residents. The Administrator was notified on 2/16/26 of the past noncompliance which began on 1/27/26. The residents were separated, and Resident #2 was placed on 1:1 observation. Resident #1 was transferred to the hospital for evaluation and treatment and returned to the facility with no new orders. Resident #2 was transferred to the hospital for psychiatric evaluation and admitted . [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide individualized and customized activities based on the resident's previous lifestyle (occupation, family, hobbies), preferences and comforts, failed to ensure to individualized activities for resident who are bed-bound or unable to participate in group activities for one sampled resident (Resident #118) and failed to provide cognitively appropriate activities for residents residing in the memory care unit, out of 29 sampled residents and potential affect all 27 residents residing on the memory care unit. The facility census of 140 residents. Review of the facility's Activities Policy revised on 8/1/25 showed:-The facility will provide an ongoing activity program to support resident choices of activities based on their comprehensive assessment, care plan and preference for each resident. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain that all foods were up to date and not expired in the walk in refrigerator; keeping the walk in refrigerator floor dry, ice buildup in the walk in freezer; black hose that connects to the cooling unit was falling apart and had insulation sticking out of it; ice and food on the floor of the walk in freezer. This practice potentially affected 140 residents who ate food from the kitchen. The facility census was 140 residents. Sanitation Inspection policy date implemented 9/1/21 showed:It was the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service area were clean, sanitary and in compliance with applicable state and federal regulations. [...]

Inspectors wroteBased on observation and interview the facility failed to maintain a faucet in resident room [ROOM NUMBER] in good repair and failed to maintain the cleanout (a capped pipe that provides access to a sewer or drain line, allowing for inspection, cleaning, and maintenance of the system) cover on the 300 Hall secured tightly to the cleanout valve. This practice potentially affected 23 residents and any facility staff who worked on the 300 Hall. The facility census was 140 residents. Observation on 8/13/25 at 10:35 A.M. and 3:39 P.M., showed the cleanout cover moved when it was stepped on. During an interview on 8/13/25 at 3:39 P.M., the Facility Maintenance Director said he/he did not know the cleanout cover needed to be tightened. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure there was negative airflow in required areas such as restrooms and soiled utility rooms in the following rooms: resident room [ROOM NUMBER], 311, 309, 306/307, 306/304, 305, 303, 302/300, 301, 210, 208, 102, 607, 603, 512, 511, 510, 508, 507, 506, 503, 502, 406, 407, 404, This practice potentially affected 44 residents. The facility census was 140 residents. **Note: Air flow was tested by holding one piece of tissue paper to the ceiling vent. If the paper was drawn to the vent, then negative air flow was present; if the paper fell, then negative airflow was absent. 1. Observations on 8/13/25 with Maintenance Person A, showed the following:-At 3:35 P.M. there was the absence of negative air flow in the shared restroom of resident rooms 310/308.-At 3:40 P.M. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician responded to the pharmacist's recommendation for a gradual dose reduction of two psychotropic medications for one sampled resident (Resident #6) out of 29 sampled residents. The facility census was 140 residents. Review of the facility's Medication Regimen Review and Reporting policy and procedure revised 9/2018, showed the Medication Regimen Review is a thorough evaluation of the medication regimen of the resident with the goal of promoting the positive outcomes and minimizing adverse consequences and potential risks associated with medication. The medication review includes review of the medical record in order to prevent, identify, report and resolve medication-related problems, medication errors, or other irregularities. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the fall investigation was completely documented and the post fall documentation was correct to show the resident's change in condition after a fall with injury for one sampled resident (Resident #6) and failed to maintain a safe transfer for one sampled resident (Resident #143), out of 29 sampled residents. The facility census was 140 residents. Review of the facility Fall policy and procedure dated 9/1/21, showed each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. The policy showed: -Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the catheter bag and tubing (a catheter is a flexible tube inserted through a narrow opening into the bladder for removing fluid. The fluid goes into a collection bag) was kept below the bladder to prevent cross contamination and infection for one sampled resident (Resident #149) out of 29 sampled residents. The facility census was 140 residents. Review of the facility Catheter Care policy and procedure revised 8/1/25, showed it was the facility's policy to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. The policy showed staff was to ensure the drainage bag was located below the level of the bladder to discourage backflow of urine. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control practice with the enteral tube feeding (A medical devices use to provide nutrition to residents who require to resident who cannot obtain nutrition by mouth requiring supplemental nutrition) process of changing the pump tubing every 24 hours for one sample resident (Resident #45), failed to ensure infection control practice wearing Personal Protective Equipment (PPE - is equipment worn to minimize exposure to a variety of hazards. [...]

Inspectors wroteBased on observation, interview and record review, showed the facility failed to complete the correct procedure during tracheostomy care to include cleaning the inner canula, failed to use Enhanced Barrier Precautions (EBP-a set of infection control practices designed to reduce the spread of multidrug-resistant organisms (MDROs) in nursing homes. They focus on using personal protective equipment (PPE) like gowns and gloves during specific high-contact resident care activities for residents at increased risk of acquiring or known to be colonized or infected with an MDRO) upon entering the resident's room and failed to use infection control practices to prevent cross contamination during tracheostomy care for one sampled resident (Resident #15) out of 29 sampled residents. The facility census was 140 residents. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure communication was established and completed between the facility and the hospice nursing staff for one sampled resident (Resident #130) out of 29 sampled residents. The facility census was 140 residents. Review of the Hospice Service Facility Agreement policy and procedure, dated 9/1/2021 showed a communication process, including how the communication will be documented between the facility and the hospice provider, to ensure that the needs of the residents were addressed and met 24 hours per day. Review of the Nursing Facility Services Agreement signed dated 5/24/24 showed the manner in which the facility and hospice were to communicate with each other and document such communications to ensure that the needs of the patients were addressed and met 24 hours a day. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one sampled resident (Resident #2) was free from physical abuse out of 8 sampled residents when on 4/17/25 Resident #1 struck Resident #2 on the head with rock resulting in an approximately 3 centimeter (cm) laceration and a hospital visit. The facility census was 138 residents. The Administrator was notified on 4/23/25 of the past noncompliance which began on 4/17/25. The facility immediately completed education for staff on the facility's Abuse and Neglect policy, the facility's Behavior Management police and de-escalation techniques. Resident #1 was placed on 1:1 supervision until his/her transport to the hospital on 4/18/25. Resident #2 was treated. The deficiency was corrected on 4/18/25. Review of the facility's Abuse, Neglect and Exploitation Policy, dated 8/22/22, showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility management company failed to ensure payments were issued or issued in a timely manner, to Vendor A who provided necessary services to the residents. On [DATE] at 9:02 A.M., the running water to the facility was shut off for non-payment. The facility had received a 10-day notice of shut off for non-payment which expired on [DATE]. This affected all residents in the building. The facility census was 113 residents. The Administrator was notified on [DATE] at 3:56 P.M., of the Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor onsite verification. 1. Review of a facility e-mail, dated [DATE] at 11:38 A.M. showed: -An attached 10-day notice from Vendor A was sent to the facility management Account Manager for payment. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent the misappropriation of one sampled resident (Resident #1). Certified Nurses Aide (CNA) A used CashAPP (a mobile payment service that allows users to send, receive and store money digitally) for multiple withdrawals totaling $617.89 from the resident's bank account out of nine sampled residents. The facility census was 112 residents. On 1/24/25, the facility administration was notified of the past noncompliance which occurred on 1/11/25. Facility staff had subsequently been educated on abuse, neglect and exploitation protocols, resident belongings, and transactions involving resident funds. The money missing from the resident's account was replaced. The deficiency was corrected on 1/13/25. Review of the facility's Abuse, Neglect and Exploitation policy dated 8/22/22 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide an discharge notice for one sampled resident (Resident #1) which included the request for an appeal and the location to which the resident was transferred that would meet the resident's level of care out of five sampled residents. The facility census was 108 residents. Review of the facility policy entitled Transfer and Discharge (including Against Medical Advice) dated 9/1/21 showed: -It was the policy of the facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility except in limited situations when the health and safety of the individual or other residents are endangered. [...]

Inspectors wroteBased on interview and record review, the facility failed to permit one sampled resident (Resident # 1) to return to the facility after hospitalization out of five sampled residents. The facility census was 108 residents. Review of the facility policy Transfer and Discharge (including Against Medical Advice - AMA), dated 9/1/21 showed: -Discharge referred to the movement of a resident from a bed in one certified facility to a bed in another certified facility or other location in the community, when return to the original facility is not expected. -Transfer and discharge included movement of a resident to a bed outside of the certified facility whether that bed is in the same physical place or not. [...]

Inspectors wroteBased on observation and interview, the facility failed to do the following: maintain the floor of the walk-in refrigerator free of food debris; maintain the ceiling vents over the steam table and the area between the dishwasher and the food preparation table free of a grease buildup; maintain the pipes and floor under the dishwashing area free of grime; maintain the deep fat fryer free of a buildup of grease; wash the food processor between uses with a three-step process instead of a two-step process; maintain the cutting boards free of numerous grooves and areas that were not easily cleanable; and failed to maintain the milk at the south nurse's station. This practice potentially affected 89 residents who ate food from the kitchen. The facility census was 91 residents. 1. Observations on 10/16/23 from 9:15 A.M. through 1:28 P.M., showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that invoices were paid in a timely manner, so they would not be overdue, for the following entities: a pest control company, the local water company, a construction company, a Laboratory testing company, the local water company, and a laundry repair company. This practice potentially affected all residents. The facility census was 91 residents. 1. During a telephone interview on 10/23/23 at 12:44 P.M., the Customer Service Representative for the pest control company said: - The facility was not current with payments. - The last time a notice was sent to the facility was on 10/5/23. - As of the last notice, the facility owed $2,701.53. 2. During a phone interview on 10/23/23 at 12:58 P.M., the Account Person at the local water company said: - At that time the facility owed a past due amount of $4,835.63. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a quality assurance program regarding interventions of ensuring the interventions from the Registered Dietitian (RD) were included within the resident's medical record and the documentation of the volume of supplements consumed by residents, for continued issues of weight loss. This practice potentially affected at least three residents (Residents #15, #85 and #7) of 19 sampled residents. The facility census was 91 residents. 1. [...]

Inspectors wroteBased on observation interview and record review, the facility failed to ensure grime, dirt, mouse droppings debris were removed from resident rooms 810, 808, 807, 804, 803, 805, 700, 702, 705, 512, 510, 506, 505, 504, 503, 502, 501, 610, 606, 601, 604, 602, 210, 205, 206, 203. 308, 307, 304, 305, 302, and 300; to maintain the flooring without rips and tears in resident rooms [ROOM NUMBERS]; to maintain the mattresses without damaged areas in resident rooms [ROOM NUMBERS]; to maintain the tube-feeding pole free of a tube feeding substance debris; and to maintain the ceiling of the 600 Hall shower room free of peeling and chipping paint. This practice potentially affected at least 80 residents who resided in or used those areas throughout the facility. The facility census was 91 residents. 1. [...]

Inspectors wrote4. Review of Resident #42's face sheet showed he/she was admitted with a diagnosis of Schizoaffective Disorder (a mental illness that can affect your thoughts, mood, and behavior). Review of the resident's Quarterly MDS dated [DATE], showed the resident: -Had severe cognitive impairment. -Required staff supervision for eating. Review of the resident's undated Care Plan showed: -Staff were to observe and encourage the resident's intake of food and fluid and offer substitutions if the resident did not like what was being served. -Staff were required to serve and set up the resident's meals. Review of the resident's weight history showed his/her weights were: -179 pounds on 4/6/23. -175 pounds on 7/17/23. -175 pounds on 8/8/23. -170 pounds on 9/12/23. -160 pounds on 10/10/23. -A 10.6% weight loss from 4/6/23 to 10/10/23. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain breakfast foods served on the 600 Hall at or close to 120 ºF (degrees Fahrenheit) at the time of service to the resident and to maintain the lunch meal served in the Gardens at or close to 120 ºF. This practice potentially affected at least 5 residents who received breakfast room trays on the 600 Hall and at least 10 residents in the Gardens who received lunch trays. The facility also failed to prepare pureed (to make food into a paste or thick liquid suspension usually made from cooked food that was ground finely) garlic bread according to the recipe. This practice caused the pureed garlic bread to be bland. The facility census was 91 residents. 1. Observation on 10/16/23 from 9:05 A.M. through 9:13 A.M., showed the temperatures of the following foods at the steam table: - Waffles were 89 ºF. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the housekeeping Supervisor's office was free of mouse droppings; to properly affix a light fixture in the ceiling of the stairwell from the 600 Hall to the Garden's area, so that the light fixture would not be unevenly attached; to ensure the ceiling vent filter in the hallway between the North Nurse's station and the 100 Hall, was filled with a heavy buildup of dust; and to ensure the area under the vending machines were maintained free of debris. This practice affected three non-resident areas (the stairwell, the Housekeeping Supervisor's office and the vending machine area) and one resident use area throughout the facility. The facility census was 91 residents. 1. Observations on 10/18/23 with the Maintenance Director and the Regional Maintenance Director showed: [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure required negative backflow ventilation was available in the following areas. The Gardens soiled utility room, the Garden's shower room, resident room [ROOM NUMBER], the South Nurse's station soiled utility room, resident room [ROOM NUMBER], resident room [ROOM NUMBER], and the 300 Hall shower room. This practice potentially affected at least 45 residents who resided in or used those areas in the facility. The facility census was 91 residents. Note: Air flow was tested by holding one piece of tissue paper to the ceiling vent. If the paper was sucked up, then negative air flow was present; if the paper fell to the floor, then negative airflow was absent. 1. Observations with the Maintenance Director and the Regional Maintenance Director on 10/17/23, showed: [...]

Inspectors wroteBased on observation and interview, the facility failed to remove numerous dead flies that were on the window sill in the kitchen above the two compartment sink and to ensure openings in the attic area above the 500 Hall were properly sealed to prevent the entrance of birds. This practice potentially affected the kitchen area and 14 residents in the 500 Hall. 1. Observation on 10/16/23 at 9:11 A.M., 10:46 A.M. and 2:13 P.M., showed the presence of numerous dead flies on the window sill above the 2 compartment sink. During an interview on 10/16/23 at 2:24 P.M., the Dietary Manager (DM) said they need to clean that area every other day. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure privacy and dignity for one sampled resident who received incontinence care (Resident #22) out of 19 sampled residents. The facility census was 91 residents. Upon exit the facility did not provide a policy on privacy/dignity. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (a device, once activated, that alerts nursing staff help is needed in that room) was appropriate for the resident, within reach, and properly care planned, for two sampled residents (Resident #42 and #45) out of 19 sampled residents. The facility census was 91 residents. Review of the facility's policy, dated 9/1/2021, titled Call Lights: Accessibility and Timely Response showed: -Staff were to evaluate each resident for unique needs and preferences and determine if any special accommodations are needed for the resident to use the call light system. -Special accommodations will be identified on the resident's care plan and provided accordingly. -Examples of special accommodations were light touch pads, larger buttons, and brighter colors. [...]

Inspectors wroteBased on interview and record review, the facility failed to submit a Third Party Liability (TPL) form to Missouri (MO) Health Net, for one deceased resident (Resident #500) within 30 days after the death of the resident. The facility census was 91 residents. 1. Review of the medical record of Resident #500 showed the resident passed away on [DATE]. Review of the resident's Trust Account records showed the resident had $255 in his/her account on the day of death. During an interview on [DATE] (240 days after the resident's death), at 12:37 P.M., the Interim Business Office Manager (BOM) said there was not a TPL form sent after the resident passed away on [DATE]. He/She did not know why any of the previous two BOMs did not send the TPL form.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate grooming by not removing facial hair for one sampled resident (Resident #75) out of 19 sampled residents. The facility census was 19 residents. Review of the facility's policy, dated 9/1/21, titled Grooming a Resident's Facial Hair showed: -Staff were to assist residents with grooming facial hair. 1. Review of Resident #75's face sheet showed he/she was admitted with a diagnosis of a Cerebral Infarction (stroke-occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). Review of the resident's undated Care Plan showed staff documented the resident: -Was totally dependent on staff for personal hygiene. -Had communication problems and difficulty answering questions. -NOTE: No mention of facial hair in the care plan. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to follow physician's orders for wound treatments; to assess wounds weekly; to document wound care when completed, and/or to transcribe physician's orders when wound treatments changed for two sampled residents (Resident #19 and #241) out of 19 sampled residents. The facility census was 91 residents. Review of the facility's policy Documentation of Wound treatments dated 2021, showed: -The facility completes accurate documentation of wound assessment and treatments including response to treatment, change in condition and changes in treatments. -Wound treatments are documented at the time of each treatment. If no treatment is due, an indication on the status of the dressing shall be documented each shift. (i.e., clean, dry, intact). -Additional document shall include, but not limited to: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain physicians orders for use of low air loss mattress (LAL)(an air mattress covered with tiny holes that are designed to let out air very slowly which helps keep the skin dry and [NAME] away any moisture) to include the setting for the mattress, to ensure the monitor of the setting of the LAL were set for resident's weight and to ensure the mattress settings were documented in the resident's medical record for one sampled resident (Resident #1), who had pressure ulcers (damage to an area of the skin caused by constant pressure on the area) out of 19 sampled residents. The facility census was 91 residents. A facility policy for low air loss mattress was requested and not received at the time of exit. Review of the facility's policy Documentation of Wound treatments dated 2021, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe smoking for one sampled resident (Resident #53) who experienced seizures and was known by the facility to be non-compliant with smoking rules and to ensure a safe transfer was completed on one sampled resident (Resident #15) out of 19 sampled residents. The facility census was 91 residents. Review of the facility Smoking Policy dated 8/1/22, showed: -Smoking is prohibited in all areas except designated smoking areas. -All residents and family members will be notified of this policy during the admission process and as needed. -Residents who smoke will be further assessed, using a smoking assessment to determine whether or not supervision is required for smoking, or if a resident is safe to smoke at all. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control practices were maintained with the placement of Indwelling Foley catheter (a urinary bladder catheter inserted through urethra) drainage bag (catheter bag, a bag that hold drained urine) kept below the level of bladder during transfer and cares for one sampled resident (Resident #1) who at risk for infections, out of 19 sampled residents. The facility census of 91 residents. Review of the facility's Catheter Care Policy copyright 2021 showed to ensure catheter drainage bag were located below the level of the bladder to discourage backflow of urine. 1. Review of Resident #1's admission Face Sheet showed he/she was admitted with a diagnosis of Neurogenic Bladder (a disorder of urinary bladder control due to damage to the spinal cord or to the nerves supplying the bladder). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the physician's orders included monitoring of the resident's dialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally) port (a catheter used for exchanging blood to and from a hemodialysis machine and a patient) and fistula (a surgically created connection between vein and artery that allows direct access to the bloodstream for dialysis) sites; to ensure the resident's fistula and port sites were monitored and documented daily; to write a care plan that included dialysis and to ensure post dialysis documentation and monitoring was consistently completed for one sampled resident (Resident #19) out of 19 sampled residents. The facility census was 91 residents. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure three trash containers were covered during the meal service preparation and to ensure the trash was removed from the grounds around the outdoor trash dumpster. This practice affected the kitchen and one outdoor area. The facility census was 91 residents. 1. Observations on 10/16/23 at 9:25 A.M., 10:09 A.M., 10:40 A.M., 12:41 P.M., and 2:02 P.M., showed three open trash containers in the kitchen which were opened and were not being used. During an interview on 10/16/23 at 2:37 P.M., the Dietary Manager (DM) said: - He/She expected staff to cover trash containers when they were not being use. - He/She did not have a cover for the rectangle trash container and - He/She noticed all three trash containers were which still opened. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure monitoring of the communication between the contracted Hospice (comfort care provided at end of life) provider and the facility by failing to have obtain documentation by hospice nursing staff to include Nurse progress notes and Routine Visits for two sampled residents (Resident #14 and #34) out of 19 sampled residents. The facility census was 91 residents. Review of the facility's policy, dated 2021, titled Coordination of Hospice Service, showed: -The facility was to coordinate care in cooperation with hospice staff. -The facility was to communicate with hospice and document all interventions put into place by hospice and the facility. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure handwashing was completed to prevent cross contamination during incontinence care for two sampled residents (Resident #22 and #15) out of 19 sampled residents. The facility census was 91 residents. The Infection Control Policy on Handwashing was requested but was not received by the exit date. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to offer to formulate advanced directives (documents that allow one to communicate their health care preferences when decision-making capacity is lost) and/or a Durable Power of Attorney (DPOA- a person previously identified to make decisions for an individual in the event of inability to make wishes known) for three sampled residents (Resident #3, #35, and #93) out of 24 sampled residents. The facility census was 115 residents. Record review of the facility's policy Residents' Rights Regarding Treatment and Advanced Directives revised 4/30/22 showed: -On admission, the facility would determine if the resident had advanced directives. -If not, the staff would offer to formulate advanced directives in a manner that was easy to understand. -During the care planning process, the advanced directives would be periodically reviewed. 1. [...]

Inspectors wroteBased on observation and interview, the facility failed to remove mouse droppings (the excrement of certain animals, such as rodents, sheep, birds, and insects) from resident rooms 809, 605, 603, 604 and 602; to address the pungent urine odor in resident room [ROOM NUMBER] and 209; to ensure that there was not a buildup of dust on the wall mounted fan in the therapy room; to ensure there was not a buildup of dust on the area where the blades join to the motor of the ceiling fan in the North Family Room; and to ensure the pillows in resident room [ROOM NUMBER] and 301 were maintained in a easily cleanable condition. This practice potentially affected at least 40 residents who resided in or used those areas within the facility. The facility census was 115 residents. 1. Observation on 5/20/22 at 2:05 P.M., of resident room [ROOM NUMBER] showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to have care plan conferences for three sampled residents (Resident #3, #48, and #5) to ensure a person centered care plan was reviewed and revised on a quarterly basis out of 24 sampled residents. The facility census was 115 residents. Record review of the facility's Care Planning - Resident Participation policy, revised 4/30/22 showed: -The facility supports the resident's right to be informed of and participate in his/her care planning and treatment. -The facility will inform the resident in a language he/she can understand of his/her rights regarding planning and implementation of care, including the right to be informed of his/her total health status. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the correct diet and needed assistance was provided to one sampled resident (Resident #5) who had experienced significant weight loss and was dependent upon staff to provide his/her meals and who required supervision and encouragement during meals; to ensure the correct diet orders were provided at meals and failed to provide assistance with meals for one sampled resident (Resident #84) with weight loss; to ensure one sampled resident (Resident #35) with protein calorie malnutrition (the state of inadequate intake of food) received the correct diet orders at meals; and to notify the physician and obtain physician's orders to increase one sampled resident's (Resident #106) tube feeding following a weight loss as recommended by the Registered Dietician (RD), out of 24 sampled residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident receiving dialysis had a correct physician's order indicating when the resident was to go for dialysis treatment; to obtain orders directing staff to monitor the Central Venous Catheter (CVC) and to ensure communication between the facility and dialysis center was maintained and ongoing to ensure the continuum of care for one sampled resident (Resident #35) out of 24 sampled residents. The facility census was 115 residents. Record review of the facility's undated Hemodialysis policy showed: -The facility would have on-going communication and collaboration with the dialysis facility regarding dialysis care and services. -If a resident had catheter access (also called a Central Venous Catheter-CVC: [...]

Inspectors wroteBased on interview and record review, the facility failed to have a system in place to ensure Certified Nurse Assistants (CNAs) received the required 12 hours in-service education; to ensure competencies were completed, and to provide dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses) education based on performance reviews annually. The facility census was 115 residents. A policy was requested and not received by the facility. 1. Record review of the last year of training included the following: -On [DATE] a training on medication pass, borrowing medications from other residents. -On [DATE] abuse and neglect. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to apply a process of coordination between the nursing and dietary departments; and to implement a system of monitoring test trays (a food tray that is evaluated for quality, including taste and temperature of a meal during a normal meal service and used to identify any areas for improvement) to ensure that food temperatures of room tray meals were maintained at or close to 120 degrees Fahrenheit (ºF ) at the time of delivery, for at least 8 residents who were served later in the delivery process on 300 Hall on 5/19/22 and at least 10 residents who were served later in the delivery process on 500 Hall on 5/23/22. The facility census was 115 residents. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the kitchen floor free of debris; to maintain the walk-in floor free of debris; to place a date on the tray that the ground meat was pulled from the freezer for slackening; to maintain the ceiling vents and light fixtures free of dust and grease buildup; to maintain the utensil storage drawers free of food debris; to ensure the light fixture over the dishwasher area illuminated; to ensure three utensils were maintained in an easily cleanable condition; to ensure that all employees wore hair coverings to cover their hair completely; and to check the temperature of eggs before placing then on a plate for service to a resident. This practice potentially affected 111 residents who ate food from the kitchen. The facility census was 115 residents. 1. Observations on 5/19/22, from 8:42 A.M. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the lids of the outdoor dumpster was closed on 5/19/22, 5/24/22 and 5/25/22. This practice potentially affected the outdoor premises of the facility with the potential of pest harborage. The facility census was 115 residents. 1. Observation on 5/19/22 at 10:27 A.M., showed the lid to the outdoor dumpster lid was open. Observation on 5/19/22 at 10:32 A.M., showed two employees went to the dumpster to dump trash. Observation on 5/19/22 at 10:44 A.M., and 12:04 P.M., showed the dumpster lid was open. Observation on 5/24/22 at 8:33 A.M., showed the lid to the outdoor dumpster was open. During an interview on 5/24/22 at 8:37 A.M., the Administrator said facility staff should close the lid after they dump trash into the dumpster and he/she has ordered a second dumpster, but it has not arrived as yet. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to notify the State Agency (SA) of an injury of unknown origin for one sampled resident (Resident #73) out of 24 sampled residents. The facility census was 115 residents. Record review of the facility's Abuse, Neglect and Exploitation policy dated 3/28/22 showed: -The facility should report to the SA immediately, but no later than two hours after the allegation was made if the events that caused the allegation involved abuse or resulted in serious bodily injury. -Not later than 24 hours if the events that caused the allegation do not involve abuse and did not result in bodily injury. 1. Record review of Resident #73's admission Record showed he/she was admitted to the facility on [DATE] with the following diagnoses: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to investigate an injury of unknown origin to determine if abuse occurred for one sampled resident (Resident #73) out of 24 sampled residents. The facility census was 115 residents. Record review of the facility's Abuse, Neglect and Exploitation policy dated 3/28/22 showed: -Possible indicators of abuse were physical injury of an unknown source. -The facility should focus on the investigation and determine if abuse or neglect had occurred focusing on the extent and the cause. -Provide complete and thorough documentation of the investigation. 1. Record review of Resident #73's admission Record showed he/she was admitted to the facility on [DATE] with the following diagnoses: [...]

Inspectors wroteBased on interview and record review,the facility failed to accurately code the Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning) for two sampled residents (Resident #48 and #37) out of 24 sampled residents. The facility census was 115 residents. 1. Record review Resident #48's admission Record showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Schizophrenia (a long-term mental disorder of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation). -Anxiety Disorder (a psychiatric disorder causing feelings of persistent dread, that can interfere with daily life). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received appropriate treatment and services to prevent urinary tract infections (UTI) for one sampled resident (Resident #93) with an indwelling urinary catheter (a sterile tube inserted into the bladder to drain the urine from the bladder) out of 24 sampled residents. The facility census was 115 residents. The facility did not have a policy regarding catheter placement during transfers. 1. Record review of Resident #93's admission Record showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Neuromuscular dysfunction of the bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems). -Stroke. Record review of the resident's Clinical Physician Orders sheet showed on 10/27/21 an order for indwelling catheter for wound healing. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the kitchen floor in good repair; to maintain the threshold to the walk-in fridge in good repair; to maintain the area under the Garden's area breakroom refrigerator clean and free of food of debris; to maintain the window blinds in resident rooms [ROOM NUMBER]; to maintain the window pane (single sheet of glass in a window or door) in resident room [ROOM NUMBER] in good repair; to ensure the restroom door in resident room [ROOM NUMBER] closed to provide privacy; to maintain the commode seats in resident rooms 506, 503 and 602; and to ensure the cold side of the faucet in resident room [ROOM NUMBER], had a knob to turn the cold side of the water on. This practice potentially affected at least 15 resident who resided in or used those areas. The facility census was 115 residents. 1. [...]