Arbor Hills Care & Rehab Center

Inspectors wroteBased on observation, interview and record review, the facility failed to store and serve food in accordance with professional standards for food service safety. The facility failed to ensure food items were dated and covered and failed to remove dented cans from the storage room. The facility also failed to maintain kitchen equipment in a clean condition during three of four days of observation and failed to ensure a sheet of ice was removed from the threshold of the walk-in freezer. In addition, the facility failed to utilize safe and sanitary food handling techniques when staff handled food from the steam table using gloved hands instead of utensils, used the steam table line as a cutting board, and mashed food for mechanical soft diets with gloved hands during one of two kitchen meal service observations. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with dignity and respect when staff spoke to one resident in an undignified manner (Resident #81), when the facility failed to provide adequate utensils at meals (Residents #24 and #79), and when staff stood over a resident while providing feeding assistance for one resident (Resident #9). The sample was 18. The census was 89. Review of the facility's Resident Rights policy, dated 1/28/26, showed the facility shall treat residents with kindness, respect and dignity and ensure Resident Rights are being followed. Review of the facility's admission Agreement, undated, showed:-Resident Rights:--Residents Be Treated with Respect: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure general accounting principles were followed by failing to complete monthly resident trust fund (RTF) reconciliations, resulting in the inability to accurately account for money held in the RTF account. In addition, the facility failed to provide quarterly statements to residents and their representatives. The facility held funds for 44 residents. The census was 89. Review of the facility's Resident Trust policy, undated, showed:-Policy: The facility shall provide a RTF cash box and a separate bonded interest-bearing bank account for all residents who choose to have their personal money safeguarded and managed by the facility. The resident or their legal guardian are the only ones who can designate what the monies are spent on and have the right to request their RTF ledger at any time;-Procedures: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide residents and/or resident representatives a bed hold policy at the time of transfer or as soon as practicable when residents were transferred to the hospital for two residents (Resident #83 and #8). In addition, the facility failed to send a copy of discharge notices to the representative of the Office of State Long Term Care (LTC) Ombudsman. The census was 89. Review of the facility's Resident Bed Hold policy, dated revised on 9/16/25, showed:-The Facility shall have a process in place to notify residents and/or their representatives in writing of the facility's bed-hold policy in advance of being transferred to the hospital or when taking therapeutic leave of absence from the facility. In the event of an emergency transfer, the notice shall be provided within 24 hours.1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were stored in accordance with acceptable standards of practice. The facility identified three medication rooms and seven medication/treatment carts. Two medication rooms and four medication/treatment carts were sampled for medication storage. Issues were found with both medication rooms and three out of four medication/treatment carts when staff failed to remove/discard expired medication and failed to label medications with a resident's name on it. The census was 89. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper infection control procedures when staff used non-medical-grade disinfectant wipes to clean the glucometer (device used to measure how much glucose (sugar) is present in the bloodstream) used on three residents (Residents #28, #46, and #48). In addition, the facility failed to store one resident's nebulizer tubing and mask per policy, creating a potential risk for cross-contamination and infection (Resident #52). The sample was 18. The census was 89. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one resident sampled for a Level Two Pre-admission Screening/Resident Review (PASARR) had the services and supports recommended, and failed to ensure the services and supports were on the care plan (Resident #8). The census was 89. Review of the facility's PASARR policy, revised 2/24/26, showed residents should have required PASARRs. Information obtained from the PASARR should be documented on the care plan, including needed services. Review of Resident #8'squarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/1/25, showed:-Should the staff assessment for mental status be conducted? No;-Is there evidence of an acute change in mental status? No;-Diagnoses included: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Activities of Daily Living (ADL) care needs were met for a dependent resident. The facility failed to ensure the resident received assistance in the dining room during meals and failed to ensure the resident's hands and nails were cleaned (Resident #3). The sample was 18. The census was 89. Review of the facility's policy titled ADL Care Shaving, reviewed on 07/21/22, showed: ADL care will include shaving to promote cleanliness and dignity; Review of the facility's policy titled Nail Care, reviewed on 07/21/22, showed: -The purpose of nail care is to clean the nail bed, trim nails and prevent infection;-Nails may be cleaned during bathing; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to transcribe a treatment order into the medical record timely and failed to follow physician orders when staff failed to administer the treatment as ordered for one resident sampled with wounds. The facility also failed to implement care plan interventions for pressure relief (Resident #3). The census was 89. Review of the facility's Physician Orders policy, dated 09/28/22, showed:-Physician orders shall be provided by licensed practitioners (Physicians, Nurse Practitioners, & Physician's Assistants) authorized to prescribe orders;-Orders must be recorded in the medical record by the licensed nurse authorized to transcribe such orders;-Physician orders will be transcribed to the appropriate Administration Record Medication (MAR/eMAR) or Treatment Administration Record (TAR/eTAR);- Telephone/verbal orders: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep residents free of accidents when a Certified Nurse Aide (CNA) left a resident unattended in a filled whirlpool to gather supplies. (Resident #83). While the CNA exited the spa and another staff member entered, the resident slipped down into the water. The other staff member had to pull the resident up. The resident said water got in his/her mouth. The resident told another CNA that staff tried to kill him/her and said he/she was now too scared to go back into the whirlpool. The mechanical lift the CNA said he/she used was not assessed for safety concerns after the incident occurred. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from significant medication errors for two residents (Resident #52 and #71). The failure placed both residents at risk for adverse effects and compromised therapeutic outcomes when Resident #52 was not monitored during a scheduled nebulizer treatment resulting in the treatment mask falling off the resident and Resident #71 had lidocaine patches applied for longer than recommended by the manufacturer. Sample size 18. The census was 89.1. Review of the state of Missouri Certified Medication Technician (CMT) Student Manual showed administering medications using a nebulizer: The CMT may administer inhaled medications using a nebulizer if permitted by facility policy. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders when staff failed to obtain labs and an x-ray timely for one resident (Resident #3). The sample was 18. The census was 89. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient dietary support personnel to effectively carry out the functions of the food and nutrition services. During one of two kitchen meal service observations, meals were served late and dietary staff failed to follow the menu and serve all menu items due to not having enough dietary staff. The census was 89. During an interview on 2/17/26 at 9:59 A.M., the Assistant Administrator, Director of Nursing (DON), and Corporate Nurse said mealtimes are scheduled for 8:00 A.M., 12:30 P.M., and 6:00 P.M. Review of the Schedule of Mealtimes, showed breakfast in the dining room scheduled at 8:00 A.M., lunch in the dining room scheduled for 12:30 P.M., and supper in the dining room scheduled for 6:00 P.M. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide services to identify and treat pressure ulcers (injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or friction) when staff failed to complete daily wound care as ordered for one resident (Resident #6). In addition, the facility also failed to ensure four residents, identified as at risk for development of pressure ulcers, received weekly skin assessments as ordered (Residents #6, #2, #3, and #7). The sample was 8. The census was 73. Review of the facility's Wound Care policy, dated October 2010, showed:-The purpose of this procedure is to provide guidelines for the care of wound to promote healing;-Verify that there is a physician's order for this procedure;-Review the resident's care plan to assess for any special needs of the resident. [...]

Inspectors wroteBased on observation, interview and record review,, the facility failed to ensure one resident's (Resident #2) change in condition was appropriately documented and treated after the resident missed multiple doses of medication. The facility also failed to follow physician orders to order pain medication for one resident (Resident #6). The sample size was eight. The census was 73. Review of the facility's Change in Condition or Status policy, dated 12/2016, showed:-Policy Statement: Our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status;-Policy implementation: The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that services were provided in accordance with the resident's care plan and accepted professional standards of clinical practices. The facility failed to ensure medications including torsemide (treats fluid retention), Amiodarone (heart medication), Lidocaine 4% patch, and Metoprolol (blood pressure medication) were ordered timely and administered for one resident (Resident #29) who had a diagnosis of congestive heart failure. In addition, the facility failed to ensure the resident was assessed for side rails and document a rationale for the use of side rails. The sample was 11. The census was 83. The administrator was notified on 4/28/25, of the past non-compliance. Staff were in-serviced on the side rail assessment policy and medication administration policy. The deficiency was corrected on 3/5/25. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored per acceptable standards of practice. The facility identified three nurse medication carts and three medication rooms. Three of the three nurse medication carts were checked, and issues were found with all three carts. Staff failed to store Ativan (lorazepam, a controlled substance used to treat anxiety) liquid medication in the refrigerator, as it is labeled to be stored in the refrigerator, and had it stored in the nurse medication cart narcotic lock box. The sample was 9. The census was 83. Review of the facility's Storage of Medications policy, revised April 2007, showed: -Policy Statement: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. -Policy Interpretation and Implementation: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two out of 17 sampled residents were free from abuse. Certified Nurse Aide (CNA) N yelled at Resident #6 in the dining room and pulled on the resident's arm- telling the resident he/she needed to leave and eat in their room, causing the resident to cry and be afraid. CNA G scolded Resident #7 when he/she yelled for assistance with continence care, due to not having a call light within reach. CNA G told the resident it was the last time he/she was going to care for the resident in bed, causing him/her to feel hurt and disrespected. During a later event, CNA G spoke disrespectfully towards the resident while walking past them. The census was 86. Review of the abuse prevention policy, dated 9/16/24, showed: -Prevention and reporting: Suspected resident/patient abuse, neglect and/or misappropriation of property; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to notify the Primary Care Physician and obtain orders for pressure ulcers (ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) when they were first identified for two residents (Resident #2 and #5) out of three sampled residents. The facility also failed to administer treatments as ordered and failed to have consistent documentation of the wounds. The census was 84. Review of the National Pressure Ulcer Advisory Panel (NPUAP), prevention and treatment of pressure ulcers: quick reference guide, Washington DC: National Pressure Ulcer Advisory Panel 2014 showed the following: -Assess the pressure ulcer initially and re-assess it at least weekly; [...]

Inspectors wroteBased on interview and record review, the facility failed to address an order of increased fluids from the Primary Care Physician (PCP) on 9/10/24 and again on 11/22/24 from the Registered Dietitian (RD) for a resident with diagnoses of severe malnutrition, renal (kidney) disease and abnormal lab values, for one out of three sampled residents (Resident #3). This resulted in the resident's hospitalization with the admitting diagnoses of renal failure, hypernatremia (high sodium levels in the blood) and altered mental status. The census was 84. Review of the facility's Nutrition and Hydration to Maintain Skin Integrity policy, revised October 2010, showed: -Purpose: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure facility residents were treated with kindness, dignity and respect. Activity Aide A spoke loudly towards one resident with severe cognitive impairment when the resident dropped a plastic wrapper on the floor (Resident #9). Additionally, direct care staff openly argued and cursed at the nurses' station in front of residents (Residents #12, #13, #14 and #21) about providing showers to residents. The sample was 17. The census was 86. Review of the Resident Right Policy, dated 12/2016, showed: -Policy statement: employees shall treat all residents with kindness, respect and dignity; -Policy Interpretation and implementation: federal and state laws guarantee basic rights to all residents of the facility. These rights include the resident's right to: -A dignified existence; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to complete a thorough investigation of alleged abuse for one resident (Resident #11) per facility policy. Review of the facility investigation, provided during the onsite investigation, showed it did not include statements from staff or residents. The sample size was 17. The census was 86. Review of the abuse prevention policy, revised 9/16/24, showed: -Investigation: -When an incident or suspected incident of abuse or neglect is reported, the Administrator or designee investigates the incident with the assistance of appropriate personnel; -The investigation should be thorough with witness statements from staff, residents, family members who may be interviewable and have information regarding the allegation; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure services provided met professional standards for one out of three sampled residents (Resident #1) when staff failed to follow physician orders as written. A urine specimen was not collected until 8 days after ordered by the physician. Antibiotic treatment was also delayed. The census was 84. Review of the facility's Medication and Treatment Orders, revised July 2016, showed: -Policy Statement: Orders for medications and treatments will be consistent with principles of safe and effective order writing; -Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state; -Drug and biological orders must be recorded on the Physician's Order Sheet in the resident's chart. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary care and services for feeding assistance at mealtime for nutrition and hydration for one of three sampled residents (Resident #2) who required assistance to perform activities of daily living (ADLs). The census was 84. Review of the facility's Assistance with Meals policy, revised July 2017, showed: -Policy statement: Residents shall receive assistance with meals in a manner that meets the individual needs of each resident; -For residents requiring full assistance, nursing will remove food trays from the food cart and deliver the trays to each residents' room; -Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, Review of Resident #2's Registered Dietician note, dated 10/10/24 at 5:40 P.M., showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff maintained infection control and proper positioning of the tubing and reservoir bag, for one resident with an indwelling urinary catheter (Foley catheter (a thin, flexible tube inserted into the urethra (the tube that cares urine from the bladder to the outside of the body) to drain urine from the bladder into a collection bag) and recent history of urinary tract infection (Resident #15). The census was 86. Review of the facility's Catheter Care, Urinary policy, dated September 2014, showed: -Purpose: To prevent catheter-associated urinary tract infection (UTIs, infection of the urinary tract system); -Review the resident's care plan to assess for any special needs of the resident; [...]

Inspectors wroteSee 81JV12 Based on interview and record review, the facility failed to respond to a report that the Business Office Manager (BOM) had been placed on the Employee Disqualification List (EDL, a listing of individuals disqualified from working in a certified nursing home) indicating he/she was ineligible to work in a certified long-term care facility, and continued to employ the staff member. The Department of Health and Senior Services (DHSS) notified the facility on 10/30/24 at 11:45 A.M., that the BOM was permanently placed on the EDL on 10/22/24, and he/she was still working at the facility when surveyors began the investigation on 11/14/24. The census was 95. Review of the EDL Active Report, showed: -The BOM's name and Social Security Number; -Added: 10/22/24; -Ordered Length: Permanent. [...]

Inspectors wroteSee 81JV12 Based on interview and record review, the facility failed to ensure residents were free from significant medication errors. Staff failed to discontinue a medication used to lower blood sugar as ordered for one resident (Resident #13). The census was 95. Review of the facility's Medication and Treatment Orders Policy, dated 7/2016, showed the following: -Policy: Orders for medications and treatments will be consistent with the principles of safe and effective order writing; -1. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such such medication in this state; -3. Drug and biological orders must be recorded on the physician's order sheet in the resident's chart; -4. All drug and biological orders shall be written, dated and signed by the person lawfully authorized to give such an order; -9. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the vehicle used to transport residents was in proper working order, free from debris, and free from exposed wires. This had the potential to affect all residents who used the van. The facility also failed to ensure a completed and thorough investigation was performed and documented after each resident fall for two out of 10 sampled residents (Resident #5 and Resident #6). The census was 86. Review of the facility's Safety and Supervision of Residents policy, undated, showed: -Policy Statement: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities; [...]

Inspectors wroteBased on interview and record review, the facility failed to respond to a report that the Business Office Manager (BOM) had been placed on the Employee Disqualification List (EDL, a listing of individuals disqualified from working in a certified nursing home) indicating he/she was ineligible to work in a certified long-term care facility, and continued to employ the staff member. The Department of Health and Senior Services (DHSS) notified the facility on 10/30/24 at 11:45 A.M., that the BOM was permanently placed on the EDL on 10/22/24, and he/she was still working at the facility when surveyors began the investigation on 11/14/24. The census was 95. Review of the EDL Active Report, showed: -The BOM's name and Social Security Number; -Added: 10/22/24; -Ordered Length: Permanent. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from significant medication errors. Staff failed to discontinue a medication used to lower blood sugar as ordered for one resident (Resident #13). The census was 95. Review of the facility's Medication and Treatment Orders Policy, dated 7/2016, showed the following: -Policy: Orders for medications and treatments will be consistent with the principles of safe and effective order writing; -1. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such such medication in this state; -3. Drug and biological orders must be recorded on the physician's order sheet in the resident's chart; -4. All drug and biological orders shall be written, dated and signed by the person lawfully authorized to give such an order; -9. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a resident with outlined food preferences to meet the needs of one of 3 sampled residents (Resident #4). The census was 86. Review of the facility's Tray Identification policy, undated, showed: -Appropriate identification shall be used to identify various diets; -To assist in setting up and serving the correct food trays/diets to residents, the Food Service Department will use appropriate identification to identify the various diets. Review of Resident #4's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/20/24, showed: -Understood, understands, clear comprehension; -Cognitively intact. Review of the Resident #4's care plan, dated 6/21/24, showed: -Assess the resident's likes and dislikes and attempt to accommodate; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide timely basic life support, including cardiopulmonary resuscitation (CPR, a lifesaving technique that's used in emergencies in which someone's breathing or heartbeat has stopped) for one of four sampled residents, who was found by staff without a pulse (Resident #1). The resident expired. The facility also failed to have a code status for one resident (Resident #2), failed to have adequate supplies on the crash cart to allow staff to respond appropriately to an emergency situation, and failed to have a CPR certified staff member on each shift. The census was 82. The Administrator was notified on [DATE] at 3:02 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. [...]

Inspectors wroteBased on observations, resident and staff interviews, record review, and facility policy review, the facility failed to ensure two of three residents (Resident (R)54 and R45) reviewed for abuse out of a total sample of 24 did not engage in verbal threats that escalated to physical abuse of kicking and slapping each other. R45 suffered psychosocial harm following the incidents as evidenced by her fearful comments to her psychiatric Nurse Practitioner and to other staff members.

Inspectors wroteBased upon record review, interview, and observations, the facility failed to implement pressure ulcer interventions after surgery for left hip repair and failed to follow physician's treatment orders for one of four residents (Resident (R) 63) reviewed for pressure ulcers out of a total sample of 24 residents. This failure caused actual harm when R63 acquired unstageable pressure ulcers on the left foot.

Inspectors wroteBased on interviews, review of the Payroll Based Journal (PBJ) staffing report, and nursing schedules from 10/01/23 to 12/31/23, the facility failed to ensure the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for 22 of the 92 days reviewed. Failure to have an RN on duty for eight consecutive hours a day has the potential to affect the care provided to residents and the supervision of the unit.

Inspectors wroteBased on interview and record review, the facility failed to develop, initiate, or revise, if necessary, a facility assessment to determine what resources were necessary to care for its residents competently during day-to-day operations. The lack of an adequate facility assessment had the potential for residents' needs to go unmet and/or result in a lack of services provided by the facility to competently care for 78 residents who resided at the facility at the time of the survey.

Inspectors wroteBased on interview and policy review, the facility failed to develop a Quality Assurance and Performance Improvement (QAPI) program. This had the potential to affect 78 of 78 residents who resided at the facility.

Inspectors wroteBased on interview and review of facility documentation, the Quality Assurance (QA) committee failed to identify quality deficiencies, , develop or implement corrective actions, , track, and measured for effectiveness or develop new interventions based on the QA committee discussions. This failure had the potential to affect 78 of 78 residents who resided at the facility.

Inspectors wroteBased on interview and review of facility documentation, the Quality Assurance (QA) committee failed to meet, at least quarterly, with the required members resulting in the potential for missed opportunities with identifying, tracking, and measuring quality deficiencies. This failure had the potential to affect 78 of 78 residents who resided at the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure resident funds were placed in an account separate from the facility operating account. The facility did not provide residents with refunds of their personal funds from the operating account in a timely manner for six residents (Residents #1016, #1019, #1027, #1028, #1029, and #1030). Secondly, the facility staff failed to obtain written authorization from the resident and/or financial guardian for money withdrawn for 19 residents (Resident #1001, #1002, #1003, #1004, #1005, #1006, #1007, #1008, #1009, #1010, #1011, #1012, #1013, #1014, #1015, #1019, #1020, #1023, and #1025) out of a sample of 20. [...]

Inspectors wroteBased on record review and interview, the facility failed to maintain a system to ensure the resident trust fund account was managed in accordance with proper accounting principles by not maintaining an accurate accounting of all monies held in the resident trust fund account by not reconciling each month. The facility managed funds for 21 residents. The census was 80. 1. Record review of the facility maintained bank statements for account ending in #5015 for months 03/2023 through 12/2023 and 02/2024 - 03/2024 showed no documentation of reconciliations. Record review of the facility maintained attempted reconciliation forms for account ending in #5015, dated 09/2023 and 03/2024, showed the attempted reconciliations did not reconcile to the residents' current balance at the time of reconciliation. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide a final accounting of resident fund balances within thirty days to the individual or probate jurisdiction administering the resident's estate for one discharged resident (Resident #1020) out of a sample of three discharged and four expired residents (Resident #1019, #1023, #1025, and #1026) out of a sample of five expired. The facility census was 80. 1. Record review of the facility maintained Trust Transaction History Report dated [DATE], showed Resident #1020 discharged on [DATE]. Record review of the facility maintained Trust Transaction Report for the period [DATE] through [DATE], showed Resident #1020 had $30.00 deposited on [DATE] and was not refunded as of [DATE], 33 days after discharge date . [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an adequate surety bond for the resident trust fund account in the amount of one and one half times the average monthly balance for the past 11 months. The census was 80. Review of the resident trust account for the past 12 months, from March 2023 through February 2024, (excluding the December 2023) showed an average monthly balance of $26,000.00 (this would yield a required bond in the amount of $39,000.00 (one and one half times the average monthly balance)). Review of the bond report for approved facility bonds by the Department of Health and Senior Services (DHSS), showed an approved bond of $4,000.00, dated 8/23/21. Review of the resident trust current balance report for February 2024, showed an amount of $13,782.56 in the trust account. [...]

Inspectors wroteBased on observations and interviews, the facility failed to post the location of the state survey results and provide unrestricted access to residents and visitors, resulting in the potential for current residents, visitors, and potential residents not to be able to review the survey results and the facility's plans of correction (POC).

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to issue an accurate Notice of Medicare Non-Coverage (NOMNC) when Medicare Part A service was ending for three of three residents (Residents (R) 1, R25, and R67) reviewed out of a total sample of 24 residents. This failure could have led the residents or their responsible party to miss the deadline to request an expedited appeal and review.

Inspectors wroteBased on record review and interview, the facility failed to ensure three residents (Residents #1008, #1010, and #1019) were free from misappropriation of resident property when the Business Office Manager used resident funds for his/her personal use. The census was 80. 1. Record review of the facility maintained Trust Transaction Report for the period 05/01/23 through 05/07/24, showed a withdrawal from Resident #1019's account: Date Amount Description 10/10/23 $5,175.00 Funeral Home Record review of the facility maintained documentation showed check #1046 in the amount of $5,175.00, dated 10/10/23, made payable to Resident #1019's family member. Record review of the facility maintained documentation showed the Business Office Manager provided a Statement of Funeral Goods and Services Selected from a funeral home in Maplewood, MO showing the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure newly hired employees were screened to rule out the presence of a Federal Indicator, with the Certified Nurse Aide (CNA) Registry for three staff members. In addition, the facility failed to check for nursing licensing for one Registered Nurse (RN) and three Licensed Practical Nurses (LPN). A sample of 10 employees hired were reviewed. The facility hired at least 200 new employees since the last survey. The census was 80. Review of the facility's Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating Policy, dated April 2021, showed the following: -Policy: [...]

Inspectors wroteBased on observation, interviews, and review of facility policy, the facility failed to ensure daily staffing was posted timely and in a manner that visitors and residents had access to this information. This deficient practice has the potential to affect all residents and visitors.

Inspectors wroteBased on record reviews and staff interviews, the facility failed to maintain a complete and accurate medical record to include required Preadmission Screening and Resident Review (PASRR) Level I and Level II, if applicable, evaluations for mental illness or intellectual disabilities for three of 24 sampled residents. This failure to have the PASRR screening results increased the risk that residents with mental illness or intellectual disabilities would not get all the required specialized services in the facility.

Inspectors wroteBased on observations, resident and staff interviews, and facility policy review, the facility failed to report to the State Survey Agency (SA) a verbal threat to shoot residents and staff in the facility by one of six residents (Resident (R)54) reviewed for abuse out of a total of 24 sampled residents. This failure increased the risk that additional verbal threats would continue without the SA's knowledge and opportunity to investigate.

Inspectors wroteBased on observations, resident and staff interviews, and facility policy review, the facility failed to thoroughly investigate a threat to shoot residents and staff in the facility verbalized by one of six residents (Resident (R)54) reviewed for abuse out of a total sample of 24 residents. This failure to thoroughly investigate the verbal threat to shoot staff and residents increased the risk of the threat actually being carried out by R54. In addition, the facility failed to thoroughly investigate an allegation of misappropriation in accordance with their policy. The facility did not suspend the employee promptly and re-instated the employee prior to speaking with all potential witnesses. In addition, the employee accused of misappropriation made contact with one of the residents one more than one occasion, including in person.

Inspectors wroteBased on interview and record review, the facility failed to issue one of three residents (Resident (R) 1) or responsible party a notice of transfer when R1 was sent to the emergency room.

Inspectors wroteBased on interview and record review, the facility failed to issue one of three residents (Resident (R) 1) or their responsible party out of a total sample of 24 residents a bed hold notice when R1 was sent to the emergency room.

Inspectors wroteBased on observation, interview, record review, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to accurately code one of 24 residents (Resident (R) 61) for restraints. This failure placed the resident at risk for the use of restraints.

Inspectors wroteBased on observations, resident and staff interviews, record review, and policy review, the facility failed to reassess interventions for efficacy when the current behavior management interventions (both medications and nonpharmacologic interventions) were not effective in decreasing verbally and physically abusive behaviors towards other residents and staff in one of five residents (Resident (R) 54) reviewed for psychosocial and behavior management out of a total sample of 24 residents. This failure increased the risk of ongoing abusive behaviors towards residents and staff by R54.

Inspectors wroteBased on interview and record review, the facility failed to ensure that monthly medication regimen reviews were completed by the consulting pharmacy for two of 24 sampled residents (Resident (R)22 and R25), resulting in the potential for adverse side effects from unnecessary, or duplicate, medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure that medications ordered on an as needed (PRN) basis for two of 24 sampled residents (Resident (R)22 and R25), included a stop date no later than 14 days after receipt of the order, resulting in the potential for adverse side effects from unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to notify a resident's responsible party after new skin conditions, which required treatment, were identified, for one of 10 sampled residents (Resident #1). The facility census was 69. Review of the facility's Changes in Condition Notification policy, revised 11/2022, showed: -It is the responsibility of licensed staff to contact the physician and the resident's responsible party whenever there is a change in the resident's physical, mental, or psychosocial status; -A change in condition is any assessment finding, observance, or event that deviates or has the potential to cause a deviation in the resident's usual or expected physical, mental, or psychosocial status; -Except in situations where a medical emergency exists, all notifications will be made within 24 hours of the noted change; [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent a significant medication error when staff failed to ensure a resident who receives hemodialysis (a procedure that filters wastes, salts and fluid from the blood when the kidneys are no longer healthy enough) received ordered medication to treat elevated potassium levels. The staff also failed to consult with the ordering physician on suggested medication alternatives, so the resident could begin the medication. As a result, the resident did not receive the ordered medication and the resident's blood potassium level increased (Resident #4). The potassium level increased and was detected by the dialysis staff. When the dialysis staff inquired about the ordered medications to treat elevated potassium levels, the facility staff stated the medications were not provided to the resident. The sample was four. The census was 68. [...]

Inspectors wroteBased on interview and record review, the facility failed to do neurological checks (neuro-checks, an assessment completed by nursing staff to monitor for changes in the resident's neurological (nervous system) status) in accordance with the facility's policy for a resident with repeated falls (Resident #4). The sample was 12. The census was 60. Review of the facility's Falls-Clinical Protocol policy, revised March 2018, showed: -Assessment and recognition: After a fall the nurse shall assess and document/report the following: -Vital signs; -Recent injury, especially fracture or head injury; -Musculoskeletal function, observe for change in normal range of motion (ROM) and weight bearing; -Change in condition and level of consciousness; -Neurological status; -Pain; -Frequency and number of falls; -Precipitating factors and details on how fall occurred; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to document assessment of pain and effectiveness of pain relief medications and provide pain management in accordance with the resident's physician orders (Resident #7). The sample was 12. The census was 60. Review of the facility's pain assessment and management procedure, revised 3/2015, showed: -Purpose: The purpose of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain; -General Guidelines: -2. Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals; -3. [...]