Appleton City Manor

Inspectors wroteBased on interview and record review, the facility failed to provide care that reflected the resident's wishes as expressed by the resident's advance directives (written instruction, such as a living will or durable power of attorney, relating to the provision of health care when the individual is incapacitated) when the facility failed to ensure one resident's (Resident #1) CPR order (CPR - a medical intervention used to restore circulatory and/or respiratory function) was clearly and consistently documented in the resident's chart resulting in staff failing to provide CPR when the resident was found unresponsive. The facility census was 35. The Administrator was notified on [DATE], at 5:10 P.M., of the Immediate Jeopardy (IJ) which occurred on [DATE]. The IJ was removed [DATE] as confirmed by surveyor on-site verification. [...]

Inspectors wroteBased on interviews and record review, the facility failed to keep residents free from accidents when one staff (Certified Nurse Aide (CNA) A) assisted one resident (Resident #1) in a hurried manner resulting in a fall from a wheelchair. The facility census was 31. Review of the facility's policy titled, Repositioning, dated 2001, showed staff to ask the resident's permission to reposition or assist in the resident in repositioning. Review of the facility's policy titled, Safe Lifting and Movement of Residents, dated 2001, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to acknowledge, assess, provide supportive services, and to develop a care plan that showed interventions the facility staff would take to try to protect the resident and prevent trauma from recurring for one resident (Resident #21), out of 8 sampled residents, who informed staff of past trauma. The facility census was 26. Review of the facility's policy entitled Behavior Health Services, undated, showed the following:-Residents in the community will receive necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and care plan;-Identify the population of the following residents in the facility assessment. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure each resident's entire drug/medication regimen was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being when staff failed to provide adequate monitoring for one resident's (Resident #21) hypertensive (high blood pressure) medications when staff failed to obtain blood pressure readings prior to administering the medication. A sample of 8 residents was reviewed in a facility with a census of 26. Review of the facility's policy titled Administering Oral Medications, revised October 2010, showed the following:-Verify there is a physician's medication order for this procedure;-Perform any pre-administration assessments;-Allow the resident to swallow oral tables at his/her pace.1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents were free from significant medication errors when staff failed to administer a controlled medication (Klonopin - medication that enhances the activity of chemical messengers to transmit signals to other nerve cells in the brain, used to treat seizures and panic disorder in adults, regulated by the government due to its potential for abuse and addiction) as order for two residents (Resident #24 and Resident #22) out of a sample of 15 residents in a facility with a census of 26. [...]

Inspectors wroteBased on record review and interview, the facility failed to maintain a complete infection prevention and control program to help prevent the development and transmission of communicable diseases and infections when staff did not complete admission tuberculin (TB - an infectious disease caused by bacteria that most often affects the lungs) testing/screening (also known as Mantoux test or tuberculin skin test (TST)) for two residents (Residents #179 and #24) who did not have their first TB test completed or documented in a timely manner. The facility had a census of 26. Review of the facility's policy entitled Tuberculosis, Screening Residents for F880, undated, showed the following:-This facility shall screen all residents for TB infection and disease; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all allegations of possible abuse were reported to the Department of Health and Senior Services (DHSS) within the required two hours timeframe when the facility did not report one resident's (Resident #1) statement threatening physical violence towards other residents. The facility census was 28. Review of facility policy titled, Abuse Prohibition, Prevention, Investigation, Reporting and Response, updated 09/26/16, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an environment that remained as free of possible hazards as possible when one resident (Resident #4) was found to have marijuana and unknown pills on their person and in their room. The facility also failed to educate staff and implement interventions to prevent future occurrences for the resident. The facility census was 28. Review of the facility's policy titled Incident/Accident Policy, dated 07/15/99, showed the following: -Document any incident occurring out of the normal, to any resident, employee, or visitor. When an incident occurs with a resident, employee or visitor, there should be an incident report made out as to name, what occurred, and if any injury was noted. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed ensure each resident received needed behavioral health care when the facility failed to develop and implement resident specific nonpharmalogical interventions for one resident (Resident #1) who exhibited signs and symptoms of psychosocial distress. The facility's census was 28. Review of the facility's Treatment/Services for Mental/Psychosocial Concerns Policy, undated, showed the following: -The facility will ensure that a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate medically related social services for one resident (Resident #1) who had a history of depression, when the Social Services Designee (SSD) did not address or assist with finding the root cause of the resident's yelling and cursing behaviors, refusal of cares, and general unhappiness living at the facility. The facility census was 28. Review of the facility's Treatment/Services for Mental/Psychosocial Concerns Policy, undated, showed the following: -The facility will ensure that a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an effective infection control program when the facility failed to implement enhanced barrier precautions (EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities) and when staff failed to follow infection control practices, per standard of practice, when staff failed to wash or sanitize hands at appropriate times during wound care to two residents (Resident #1 and Resident #2) out of a sample of three residents. The facility census was 29. Review showed the facility did not provide a policy for Enhanced Barrier Precautions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care per standards of practice when staff failed to consistently assess and document complete, thorough, and accurate weekly skin assessments, failed to complete weekly wound tracking, and failed to obtain treatment orders for all wounds for one resident (Resident #1) with pressure ulcers (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) out of a sample of three residents. The facility census was 29. Review of the facility policy titled, Treatment/Services to Prevent/Heal Pressure Ulcers, undated, showed the following: [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure the home had registered nurse (RN) coverage including a RN assigned to serve as the Director of Nursing (DON) and able to complete needed DON duties on a full time basis when the facility's DON provided routine floor coverage prior to leaving employment at the facility. This resulted in leaving the facility being without a DON or RN. The facility census was 38. Review of the facility's policy titled, Nursing Services, undated, showed the following: -It is the policy of the facility to assure that there is sufficient qualified nursing staff available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being; [...]

Inspectors wroteBased on interview and record review, the facility failed to manage and account for all residents' personnel funds as required when staff failed to deposit residents' personal funds in excess of $50.00 into an interest bearing account and credit all interest earned back to residents for two residents (Resident #1 and #5) who received Medicaid services and when the facility failed to properly maintain an ongoing balance of and reasonable resident access to funds for seven residents (Resident #1, #5, #10, #21, #23, #28, and #100) personal funds. The facility census was 38. Review of the facility policy titled Resident Right - Protection/Management of Personal Funds, undated, showed the following: -It is the policy of the facility to protect and manage the personal funds of the resident in such a manner to acknowledge and respect resident rights; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were as free from accident hazards as possible when staff failed to follow physician orders to safely transfer one resident (Resident #7) using a Hoyer lift (mechanical device with a sling attached to lift and transfer a non-ambulatory resident). The facility had a census of 38. Review of the facility's policy, Hoyer Lift and Sit to Stand Lift Policy and Procedure, undated, showed the following: -Operating the Hoyer and Sit to Stand Lift is always and only a two-person operation. Do not operate lifts by self; -Any staff transferring a resident in a lift by themselves will be immediately terminated; -Always explain the steps to the resident; -Always double check sling attachment to Hoyer lift bar before lifting resident. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide care per standards of practice for all residents when staff failed to administer medications as ordered, failed to monitor the resident as ordered, and failed to notify and follow-up with the physician as ordered and in a timely manner for one resident (Resident #23) with edema (fluid retention) resulting in increased edema, weight gain, and an inability of the resident to wear his/her shoes. The facility census was 38. Review showed the facility did not provide a policy related to monitoring of changes in condition. Review of the facility policy, Medication Administration Policy and Procedure, undated, showed the following: -Medications are administered to residents in a safe, efficient, timely manner in accordance with accepted standards of practice and resident's usual preferred routine; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the services of a registered nurse (RN) for at least eight consecutive hours per day seven days per week. The facility census was 37. Review of the facility's policy Nursing Services, undated, showed the following: -It is the policy of the facility to assure that there is sufficient qualified nursing staff available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being; -Except when waived, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week; -The Director of Nursing (DON) may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure eight nurse aides (NA) (NA D, NA E, NA H, NA I, NA K, NA L, NA M, and NA N) of eight sampled NAs completed a certified nurse aide (CNA) training program within four months of employment at the facility as a nurse aide. The facility census was 38. Review of the facility policy, titled CNA Certification Policy, dated 8/22/22, showed the following: -This policy was made to ensure the residents' health and safety and to meet the residents' needs; -All nursing assistants shall successfully complete the entire basic course (including passing the final examination) of the nursing assistant training program and be certified within four months of employment; [...]

Inspectors wroteBased on interview and record review, the facility failed to employ sufficiently qualified staff when the Director of Food and Nutrition Services (Dietary Manager) did not have required certification and/or experience. The facility census was 38. Review of the facility's policy titled, Dietary Services, undated, showed the following information: -The Director of Food Services (Dietary Manager) is designated by the facility administrator as responsible for the total dietetic service. The Dietary Manager receives frequently scheduled consultations from the qualified Dietitian; -Sufficient and competent dietary staff are employed to carry out the functions of the dietary services. Review showed the facility did not provide a policy regarding what the required qualifications were for a Dietary Manager. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety when the facility staff failed to keep food contact and non-food contact surfaces clean; when staff failed to ensure the refrigerators maintained proper temperatures for food storage; when staff failed to ensure stored food was properly stored/sealed; and when staff failed to ensure spoiled or contaminated foods were discarded. The facility census was 38. 1. Review of the Food and Drug Administration (FDA) Food Code (2022 edition) showed nonfood contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. [...]

Inspectors wroteBased on record review and interview, the facility failed to submit payroll based data to the Centers of Medicare and Medicaid Services (CMS) in a timely fashion as required. The facility census was 38. 1. Review of the facility's Payroll Based Journal (PBJ) Staffing Data Report, for fiscal year quarter two of 2024 (04/01/24 to 06/30/24), showed the facility triggered for failing to submit data for the quarter. During an interview on 09/06/24, at 9:21 A.M., the Administrator said that she had just started the PBJ for July, August, September. She found it had not been done for a while. She took the administrator position in July. She had completed the report for July, but was unable to go back and enter data for the previous period. She did not know who had been responsible for entering the report.

Inspectors wroteBased on interview and record review, the facility failed to implement and maintain an effective, comprehensive Quality Assurance and Performance Improvement (QAPI) plan that demonstrated identification, reporting, investigation, analysis, and prevention of adverse events, and documentation that demonstrated the development, implementation, and evaluation of corrective actions or performance improvement activities. The facility census was 38 at the time of survey. Review showed the facility did not provide a policy or procedure related to a comprehensive QAPI Plan. 1. Review of facility records showed the following: -The facility did not have documentation of Performance-Improvement-Plans (PIP's) or evidence of good-faith attempts to correct identified deficient practices;. -The facility did not have a current identified infection preventionist to participate. [...]

Inspectors wroteBased on record review and interview, the facility failed to maintain documentation of maintaining a functioning Quality Assessment and Assurance (QAA) Committee that met at least quarterly with the required members. The facility census was 38. Review showed the facility did not provide a policy regarding a QAA Committee. 1. Review of facility records showed the following: -Staff did not have documentation to show a QAA Committee met a minimum quarterly with the required members. -The facility did not currently have an Infection Preventionist to participate in a QAA Committee. -The medical director did not attempt QAA Committee meeting regularly. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to implement a complete and effective infection control program when staff failed to have a process in place to monitor for Legionella (severe form of pneumonia); failed to cover clean laundry when returning to resident rooms; failed to wear a mask or cover mouth when coughing; failed to use appropriate infection control measures to prevent or reduce the risk of spreading bacteria or other infectious causing contaminants when staff failed to provide a clean barrier for supplies for two residents (Resident #30 and #1); and when the home failed to implement an enhanced barrier precaution (EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities) policy. The facility census was 38. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement an effective and complete antibiotic stewardship program when staff failed to track residents on antibiotics for various infections in the facility by not completing a current and ongoing antibiotic log of residents with active infections and failed to care plan antibiotic usage for two residents (Resident #30 and #15). The facility census was 38. Review of the facility's policy, Infection Control - Antibiotic Stewardship, undated, showed the following: -It is the policy of the facility to support the judicious use of antibiotics in accordance with State and Federal Regulations, and national guidelines; -The facility will establish protocols for antibiotic prescribing in accordance with national guidelines and treatment protocols; -The facility will establish algorithms for appropriate diagnostic testing (example: [...]

Inspectors wroteBased on record review and interview, the facility failed to have a designated certified staff person as the infection preventionist (IP) who was responsible for the facility's infection prevention and control program (ICPC). The facility census was 38. Review showed the facility did not provide a policy related to the infection preventionist position. 1. During an interview on 09/04/24, at 11:30 A.M., the Administrator said she was unsure who was monitoring infections. She had taken the infection preventionist course, but had not taken the test. She thought possibly Licensed Practical Nurse (LPN) C was monitoring infections. During an interview on 09/04/24, at 3:35 P.M., LPN C said that he/she did not have infection preventionist certification and was not tracking infections. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement abuse policies that established steps to prevent abuse, including proper screening of staff upon hire, when the facility failed to follow-up on requested Criminal Background Checks (CBC) for four staff (Nurse Aide (NA) D, Restorative Aide (RA) G, NA I, and Certified Medication Technician (CMT) F) out of ten sampled staff. The facility had a census of 38. Review of the facility's policy Policy and Procedures for New Hires, dated 09/09/13, showed the following: -All potential new hires have a background check initiated prior to beginning employment; -No new employee will be allowed to have direct contact with a resident until this steps has been completed. 1. Review of NA D's personnel record showed the following information: -Hire date of 05/09/22; -Staff requested a criminal background check on 05/09/22; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a bed hold policy for one resident (Resident #36) who transferred/discharged to the hospital on two separate occasions. The facility census was 38. Review showed the facility did not provide a policy regarding bed holds. 1. Review of the Resident #36's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 04/24/24; -Resident had a responsible party; -Diagnoses included Alzheimer's disease and vascular dementia (disease affecting blood vessels in the brain causing changes to memory, thinking, and behavior). Review of the resident after visit summary from the hospital, dated 08/09/24, showed the resident was seen in the emergency room on [DATE] and discharged back to the facility on [DATE]. [...]

Inspectors wroteBased on record review and interview, the facility failed to complete and submit a quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff) within 92 days of the prior assessment for four residents (Residents #10, #3, #7, and #17). The facility census was 25. Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, Chapter 2, Assessments for the RAI, showed the following information: -The quarterly assessment is an Omnibus Budget Reconciliation Act of 1987 (OBRA) non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type; -The quarterly assessment is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a process in place to ensure the timely and accurate identification of code status (whether a resident wished to receive cardiopulmonary resuscitation (CPR - an emergency treatment that's done when someone's breathing or heartbeat has stopped)) for all residents when staff failed to have physician orders related to code status for three residents (Resident #36, #30, and #3) and when the medical records of two residents (Resident #11 and #26) had conflicting code status information. A sample of 15 residents was selected for review out of a facility census of 38. Review showed the facility did not provide a policy regarding advance directives or code status processes. 1. Review of Resident #36's face sheet (a document that gives a resident's information at a quick glance) showed the following: [...]

Inspectors wroteBased on observation, record review, and interview the facility failed to provide pharmaceutical services to meet the needs of each resident when staff failed to obtain and administer medications as ordered after admission for one resident (Resident #4). The facility also failed to implement an effective system of destroying medications that could not be returned to the pharmacy a timely manner for sixteen residents (Resident #191, #11, #8, #19, #37, #18, #7, #22, #4, #15, #36, #190, #32, #29, #139, and #39) The facility census was 38. 1. Review of an facility policy, Medication Administration Policy and Procedure, undated, showed the following: -Medications are administered to residents in a safe, efficient, timely manner in accordance with accepted standards of practice and resident's usual preferred routine; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure pharmacy consultant recommendations were acted upon for gradual dose reductions (GDR - a stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) in an effort to reduce or discontinue psychoactive medications for one resident (Resident #1). The facility also failed to complete monthly drug regimen reviews for three residents (Resident #17, #11, and #26). The facility census was 38. Review of the undated facility policy titled Pharmacy Services - Drug regimen free From Unnecessary Drugs, undated, showed the following: -The intent of the policy was to ensure each resident's entire medication regimen was managed and monitored to promote or maintain the resident's highest practicable wellbeing; [...]

Inspectors wroteBased on record review and interview, facility staff failed to complete an annual Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff) assessment for two residents (Resident #1 and #22) within the required 14 days from the assessment reference date (ARD). The facility had a census of 25. Record review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, Chapter 2, Assessments for the RAI, showed the following information: [...]

Inspectors wroteBased on record review and interview, the facility failed to complete and electronically transmit a discharge and re-entry Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff) for three residents (Residents #3, #7, and #30). The facility census was 25. Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, Chapter 2, Assessments for the RAI, showed the following information: -The discharge assessment is an Omnibus Budget Reconciliation Act of 1987 (OBRA) non-comprehensive resident assessment; -The discharge assessment must be completed no later than 14 calendar days after the discharge; -The MDS must be transmitted no later than 14 calendar days after the MDS completion date. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan for all residents when staff failed to complete a baseline care plan with 48 hours of admission on e resident (Resident #39). The facility census was 38. Review of the facility's Resident Assessment Policy, undated, showed the following: -It is the policy of the facility to conduct and document comprehensive assessments on all residents admitted to the facility; -Comprehensive assessments describe the resident's capability to perform daily life functions and significant impairment in functional capacity; -Comprehensive assessments will commence upon admission or readmission of a resident and be completed no later than 14 days after admission or readmission. 1. Review of Resident #39's face sheet showed the following: -admitted on [DATE]; [...]

Inspectors wroteBased on observations, interview, and record review, the facility failed to provide care per standards of practice when the staff failed to document full regular full assessments wounds, failed to update care plans of wounds, failed to notify the physician in a timely manner of new or changing wounds, and failed to ensure physician's orders were followed for all wounds for two residents (Resident #30 and #36). The facility census was 38. Review of the facility policy titled Treatment/Services to Prevent/Heal Pressure Ulcers, undated, showed the following: -The facility will ensure a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing; [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure all residents received care to help maintain or improve range of motion (ROM - full movement potential of a join) when staff failed to ensure an ordered hand split was used to consistently, was monitored, and was care planned for one resident (Resident #23). The facility census was 38. Review showed the facility did not provide a policy related to restorative care or assistive devices. 1. Review of Resident #23's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 02/09/22; -Diagnoses included intracerebral hemorrhage (bleeding into the brain tissue), hemiplegia of left side, seizures, and muscle weakness. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide incontinence care per nursing standards and in a manner to help prevent possible infection when staff failed to provide complete peri-care and failed to perform proper hand hygiene while providing peri-care for two residents (Resident #12 and #6). The facility census was 38. Review of the manual titled Nurse Assistant in Long Term Care Facility, 2001 Revision Edition, showed staff, when providing incontinent care, should wash the resident from front to back to prevent from spreading fecal matter from the anal area to the urethra (opening to bladder). Review of the facility's policy titled Incontinence Care, undated, showed the following procedure: -Wash all soiled skin areas and dry very well, especially between skin folds; -Change linen and apply linen with no wrinkles. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility to ensure all residents received recommended interventions to help maintain acceptable parameters of nutritional status when staff failed to care plan, notify the physician of, and implement the Registered Dietitian (RD's) recommendations for a dietary supplement for one resident (Resident #33) who had been identified as experiencing some weight loss. The facility census was 38. Review of the facility's policy, titled Dietary Services, undated, showed the following information: -Dietary services meet the individual nutritional needs of each resident; -The dietician develops therapeutic diets to meet the specialized need of each resident; -All therapeutic diets are prescribed by the resident's physician and/or his/her designee. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care per standards of practice for all residents when staff failed to obtain physician orders for use and care of a Continuous Positive Airway Pressure (CPAP- is a machine that uses mild air pressure to keep breathing airways open while asleep) machine and failed to care plane the use of the CPAP machine for one resident (Resident #15). The facility census was 38. Review of the facility's policy, titled Oxygen Administration, undated, showed staff to check physician's order for liter flow and method of administration. Review of the facility's policy, titled admission Orders, undated, showed the following information: -The facility will have physician orders for the resident's immediate care at the time of a resident's admission; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #36) was free from unnecessary psychotropic as needed (PRN) medications (medication affecting mind, emotions, and behavior) limited to fourteen days unless evaluated by the physician. The facility also failed to attempt a gradual dose reduction (GDR) for psychotropic medications for one resident (Resident #17). The facility census was 38. 1. Review of an undated facility policy Pharmacy Services - Drug Regimen Free From Unnecessary Drugs should the following: -PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited; -PRN orders for psychotropic drugs is limited to 14 days. Review of Resident #36's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 04/24/24; [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain all residents' records in a manner that was complete and accurate when the facility failed to document related to changes in conditions for two residents (Resident #39 and #36) that resulted transfers to the hospital. The facility census was 38. Review of facility records showed the facility did not provide a policy related to accuracy of or documentation in resident records, including changes in condition. 1. Review of Resident #39's face sheet showed the following: -admission date of 06/03/24; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the required daily nurse staffing information that included the name of the facility and the total and actual number of hours worked for each category of licensed and unlicensed staff directly responsible for resident care per shift in a prominent place readily accessible to residents and visitors. The facility census was 38. Review showed the facility did not provide a policy related to posted staffing hours. 1. Observation on 09/04/24, at 10:30 A.M., of a posting titled Staff Posting (Staff Scheduled), on a bulletin board at the nurses' station, showed the following: -Date 09/04/24; -Census: 37; -Three shifts, 6-2, 2-10, 10-6, with first names of staff working in each position; -Blank line for registered nurse (RN) name, Director of Nursing (DON) name, and Assistant Director of Nursing (ADON) name; [...]

Inspectors wrote1. Please refer to event ID NJ1P12. Based on interviews and record review, the facility failed to ensure all residents were treated with dignity and respect when staff yelled and cursed in the presence of residents. A sample of seven residents was reviewed in a facility with a census of 37. 1. Review of Resident #1's face sheet (admission data) showed the following: -admission date of 07/01/19; -Diagnoses included Alzheimer's disease (confusion or cognitive impairment), dementia with other behavioral disturbances (confusion or cognitive impairment with behaviors); and major depressive disorder (feeling low or sad persistently). Review of the resident's significant change Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 02/21/24, showed the following: -Severally impaired cognition; -Disorganized thinking present. [...]

Inspectors wrote1. Please refer to event ID NJ1P12. Based on interview and record review, the facility failed to ensure all residents' drug regimes were free from unnecessary drugs when staff failed to adequately monitor blood pressure as ordered for one resident (Resident #2), who received medications to help control blood pressure. A sample of four residents were reviewed, with a facility census of 37. Review showed the facility did not have a a policy regarding following physician's orders and monitoring with administration of medications. 1. Review of Resident #2's face sheet (admission data) showed the following: -admission date of 01/14/24; -No diagnosis listed. Review of the resident's care plan, dated 01/19/24, showed staff did not care plan regarding the resident's blood pressure medications. [...]

Inspectors wrote1. Please refer to event ID NJ1P12. Based on interview and record review, the facility failed to ensure all residents' drug regimes were free from unnecessary drugs when staff failed to specify a diagnosis for use of a psychotropic medication for one resident (Resident #1). A sample of four residents was reviewed in a facility with a census of 37. Review showed the facility did not provide a policy regarding psychotropic medications. 1. Review of Resident #1's face sheet (admission data) showed the following: -admission date of 07/01/19; -Diagnoses included Alzheimer's disease (confusion or cognitive impairment), unspecified dementia with the other behavioral disturbances (confusion or cognitive impairment with behaviors). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 02/21/24, showed the following: [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure all residents were treated with dignity and respect when staff yelled and cursed in the presence of residents. A sample of seven residents was reviewed in a facility with a census of 37. 1. Review of Resident #1's face sheet (admission data) showed the following: -admission date of 07/01/19; -Diagnoses included Alzheimer's disease (confusion or cognitive impairment), dementia with other behavioral disturbances (confusion or cognitive impairment with behaviors); and major depressive disorder (feeling low or sad persistently). Review of the resident's significant change Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 02/21/24, showed the following: -Severally impaired cognition; -Disorganized thinking present. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure all allegations of possible abuse were reported immediately to management and within two hours to the State Survey Agency (Department of Health and Senior Services - DHSS) when allegations were reported that one staff (Certified Nurse Aid (CNA A))cursed at two residents (Resident #1 and Resident # 2). The facility census was 45. Review of the facility's policy titled, Abuse, Prohibition, Prevention, Investigation, and Response, undated, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents' drug regimes were free from unnecessary drugs when staff failed to adequately monitor blood pressure as ordered for one resident (Resident #2), who received medications to help control blood pressure. A sample of four residents were reviewed, with a facility census of 37. Review showed the facility did not have a a policy regarding following physician's orders and monitoring with administration of medications. 1. Review of Resident #2's face sheet (admission data) showed the following: -admission date of 01/14/24; -No diagnosis listed. Review of the resident's care plan, dated 01/19/24, showed staff did not care plan regarding the resident's blood pressure medications. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents' drug regimes were free from unnecessary drugs when staff failed to specify a diagnosis for use of a psychotropic medication for one resident (Resident #1). A sample of four residents was reviewed in a facility with a census of 37. Review showed the facility did not provide a policy regarding psychotropic medications. 1. Review of Resident #1's face sheet (admission data) showed the following: -admission date of 07/01/19; -Diagnoses included Alzheimer's disease (confusion or cognitive impairment), unspecified dementia with the other behavioral disturbances (confusion or cognitive impairment with behaviors). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 02/21/24, showed the following: -Severally impaired cognition; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to staff a registered nurse (RN) for at least eight hours a day, seven days a week. The facility census was 40. 1. Review of the October 2023 daily staffing postings showed the following: -On 10/11/23, there were no RN hours; -On 10/14/23, there were no RN hours; -On 10/15/23, there were no RN hours; -On 10/16/23, there were no RN hours. -The facility did not provide any other daily staffing posting for October 2023. Review of the facility's daily staffing sheet showed there was no RN scheduled for any shift on 10/11/23, 10/14/23, 10/15/23, 10/17/23, 10/18/23, 10/19/23, 10/20/23, 10/21/23, 10/22/23, 10/23/23, and 10/24/23. During an interview on 11/01/23, at 12:17 P.M., Licensed Practical Nurse (LPN) C said the following: -The Director of Nursing (DON) is the only RN employed at the facility; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure seven nursing aides (Nurse Aide (NA) A, NA E, NA F, NA G, NA H, NA I, and NA J) completed a a state approved certified nursing assistant (CNA) training program and competency evaluation program within four months of hire. The facility's census was 40. Review showed the facility did not provide a policy related to certification requirements time frames for CNAs. 1. Review of the personnel records showed the following: -NA A was hired as an NA on 05/09/22; -NA E was hired as an NA on 10/08/20; -NA F was hired as an NA on 05/02/19; -NA G was hired as an NA on 04/18/19; -NA H was hired as an NA on 04/20/23; -NA I was hired as an NA on 07/28/22; -NA J was hired as an NA on 02/27/23; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the annual individual performance review or evaluation and failed to provide regular in-service education based on these reviews for five nursing aides (Nurse Aide (NA) A, NA E, NA F, NA G, and NA I) . The facility census was 40. Review showed the facility did not provide a policy regarding annual individual performance reviews or education for aides. Review of the facility's current wide assessment showed the following: -The regulation outlines that individualized approach of the facility assessment is the foundation to determine staffing levels and competencies. [...]

Inspectors wroteBased on interview and record review, the facility failed to have a registered nurse (RN) work eight consecutive hours seven days per week. The facility census was 31. Record review of the facility's Registered Nurse Coverage Policy, undated, showed the following information: -It is the policy of the facility to have RN coverage eight hours during the day for seven days a week; -The RN on duty will be responsible for supervision of the staff on duty and their provision of resident care; -The RN on duty will follow the job description of the RN. 1. Record review of the facility's provided nurse schedules, dated 07/01/2022 through 07/31/2022, showed no RN coverage on any shift for the following dates: -07/03/2022; -07/09/2022; -07/10/2022; -07/16/2022; -07/17/2022, -07/23/2022; -07/24/2022; -07/30/2022; -07/31/2022. [...]

Inspectors wroteBased on record review, observation, and interview, the facility failed to prepare food in accordance with professional standards of practice and protect food from possible contamination when staff did not maintain clean surfaces, touched food with bare hands, and staff did not wear proper hair coverings. The facility census was 31. 1. Record review of the 2013 Missouri Food Code showed the following information: -Equipment food-contact surfaces and utensils shall be clean to sight and touch; -The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; -Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection control program that provided a safe and sanitary environment for all residents related to the Coronavirus Disease 2019 (COVID-19, an infectious disease caused by severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2)) when staff failed to wear face coverings properly while working with residents. The facility also failed to provide an effective, thorough program for the prevention of the growth of the Legionella bacteria (a bacteria which causes a respiratory disease when breathing in small droplets of water in the air that contain Legionella. It can become a health concern when it grows and spreads in human-made water systems.) in the facility water supply or where moist conditions existed. The facility census was 31. 1. [...]

Inspectors wroteBased on record review, observation, and interview, the facility failed to maintain a clean, comfortable, homelike environment when multiple light fixture covers were dirty, broken, missing the cover, or had dead bugs present in the fixture. The facility census was 31. Record review showed the facility did not provide a policy regarding cleaning or maintenance of the building. 1. Observation on 08/18/2022, at 11:20 A.M., showed the following: -Fluorescent light fixture in the hall, near room [ROOM NUMBER], had dead bugs in the cover; -Fluorescent light fixture in the hall, near room [ROOM NUMBER], had a broken cracked cover across the length of the fixture; -Fluorescent light fixture, across from the soiled utility room, had approximately 12 dead bugs in the cover; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff completed Nurse Aide (NA) Registry (registry which shows if someone has a Federal Indicator (indicates individuals who had a previous incident involving abuse, neglect, or misappropriation of property that would prevent the employee from working in a certified long-term care facility)) checks for three employees (Dietary Aide (DA) N, Licensed Practical Nurse (LPN) M, and Nurse Aide (NA) L). The facility census was 31. Record review showed the facility did not provide a policy regarding checking the NA registry upon hire. 1. Record review of Dietary Aide (DA) N's personnel record showed the following: -Hire/Start date of 4/12/22; -The facility had not completed the NA registry check for the DA. 2. Record review of Licensed Practical Nurse (LPN) M's personnel record showed the following: -Hire/start date of 6/09/22; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two nurse aides (Nurse Aide (NA) I and NA J) completed a certified nurse aide (CNA) training program within four months of employment in the facility as a nurse aide. The facility census was 31. Record review of the facility policy titled CNA Certification Policy, last reviewed and revised 08/22/2022, showed the following: -This policy is to ensure the residents' health and safety and to meet the residents' needs; -All nursing assistants shall successfully complete the entire basic course (including passing the final examination) of the nursing assistant training program and be certified within four months of employment; [...]

Inspectors wroteBased on record review, observation, and interview, the facility failed to adequately equipped with a full call light system when call light pull cords were missing or when staff stored emergency call light pull cords where residents could not access the pull cord for staff assistance. The facility census was 31. Record review showed the facility did not provide a policy addressing the call light system. 1. Observation on 08/18/2022, at 11:30 A.M., showed the following: -room [ROOM NUMBER], where two residents resided, the call light pull cord in the resident's bathroom next to the toilet was missing; -room [ROOM NUMBER], where one resident resided, the call light pull cord wrapped and tied around the grab bar next to the toilet where it could not be easily access and triggered by the resident. Observation on 08/18/2022, at 1:00 P.M., showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to give written information to the resident and/or resident's representative of the facility's bed hold policy for two residents (Residents #1 and #14) who were transferred to the hospital. The facility census was 31. Record review showed the facility did not provide a bed hold policy. 1. Record review of Resident #14's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 2/08/2021; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff administered medications with an error rate of less than 5% when staff made two errors out of 27 opportunities, resulting in an error rate of 7.41%, affecting two residents (Residents #14 and #18). The facility census was 31. Record review of the facility policy, titled Kwik Pen Policy, undated, showed the following: -Priming the insulin pen means removing the air from the needle and cartridge that may collect during normal use and ensures the pen is working correctly; -Prime before each injection with 2 units. Record review of the Novolog Flex Pen (a fast-acting insulin) manufacturer's guidance, dated 3/2021, showed the following: -Before each injection small amounts of air may collect in the cartridge during normal use; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all residents were free from significant medication errors when staff administered insulin (medication used to help control blood sugar levels) without priming the insulin pens prior to administration per manufacture recommendations and standards of practice for two residents (Residents #14 and Resident #18). The facility census was 31. Record review of the facility policy, titled Kwik Pen Policy, undated, showed the following: -Priming the insulin pen means removing the air from the needle and cartridge that may collect during normal use and ensures the pen is working correctly; -Prime before each injection with 2 units. Record review of the Novolog Flex Pen (a fast-acting insulin) manufacturer's guidance, dated 3/2021, showed the following: [...]