Arbor View Nursing and Rehabilitation

Inspectors wroteBased on observation, interview and record review, the facility failed to perform a proper transfer from the chair to the bed for one resident (Resident #1), of four sampled residents. The facility census was 83. The facility did not provide a safe transfer policy and procedure. Observation of a video, dated 09/27/2025, from a camera in Resident #1's room, showed:At 8:08 P.M, Certified Nurse Aid (CNA) entered the resident's room and removed the foot pedals attached to the Geri-chair Resident #1 reclined in. [...]

Inspectors wroteBased on interview and record review, the facility failed to have a clinically qualified nutritional professional designated as the Food and Nutritional Service Manager for one of one food service kitchens, which prepared food for all residents. This deficient practice potentially affected all of the residents who were served food prepared by the facility. The facility's census was 86. Review of the facility policy titled, Qualified Dietary Staff, dated 10/01/23, showed: -The dietary/ food services department is staffed by dietary/ food and nutrition services personnel to meet the needs of the residents and the skilled Dietitian will help oversee the dietary/ food and nutrition services in the facility; -The Dietitian or nutrition professional may be full time or part time consultant or an employee, depending on the current requirements of the facility; [...]

Inspectors wroteBased on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. This deficiency had the potential to affect all residents. The facility census was 86. The facility did not provide a RN coverage policy. Review of the facility's Facility Assessment Tool, dated 4/10/24, showed: - The facility required five licensed nurses providing direct care for day shift, which included at least one RN for the day shift. Review of the Nursing Schedules and the Daily Nursing Staffing Sheets for 01/01/25 - 03/31/25, showed: - No RN coverage for eight consecutive hours on 01/06/25, 01/23/25, 01/24/25, 01/27/25, 01/30/25, 01/31/25, 02/03/25, 02/06/25, and 02/07/25; - No RN coverage for eight consecutive worked for nine days out of 90 days. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to create an environment that was respectful of the rights of each resident to make choices about aspects of their lives that were significant by providing a bathing schedule based on staff preference and not resident preference for one resident (Resident #1) and by failing to honor one resident's (Resident #24) preference to be shaved daily out of 18 sampled residents . The facility's census was 86. Review of the facility's policy titled, Resident Rights, Dignity and Visitation Rights, dated 04/01/22, showed: - It will be the policy of this facility that employees shall treat residents with kindness, respect, and dignity. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a final accounting of a resident's fund balance within 30 days to the individual or probate jurisdiction administering the resident's estate for one expired resident (Resident #87) out of one expired resident. The facility census was 86. The facility did not provide a policy regarding resident funds balance. Review of Resident #87's medical record showed: - The resident expired on [DATE]. Record of the facility maintained Trust Trial Balance, dated [DATE], showed: - Resident #87 with an account balance of $2,694. During an interview on [DATE] at 9:03 A.M., the Social Services Designee (SSD) said normally if someone passed away, their money would go towards any funeral home bills. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor and keep one resident's (Resident #54) equipment in good, working order. The facility also failed to provide a safe, clean, comfortable, and homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 86. The facility did not provide a policy regarding a safe, clean, comfortable, and homelike environment. The facility did not provide a policy regarding maintenance of residents' equipment. 1. Observation on 03/30/25 at 10:56 A.M., of Room C9 showed: - A window unit below the window with drywall placed around the top and both sides that did not completely in case the window unit. There were open areas to the top and right side of the unit with light from the outside that showed around the top of the unit. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to a hospital, including the reasons for transfer, for five residents (Residents #11, #12, #38, #46, and #59) out of 18 sampled residents and one resident (Resident #44) outside the sample. The facility's census was 86. Review of the facility policy titled, Transfer and Discharge, dated 04/01/22, showed: - It is the policy of this facility to provide appropriate transfer and discharge services, documentation that will be included in the medical record, and who is responsible for making the documentation. The facility will allow for sufficient preparation and orientation by informing the resident where he/she is going to take steps to minimize anxiety; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide written notification of their bed hold policy to the residents and/or their resident representatives at the time of transfer for four residents (Residents #11, #12, #38, and #46) out of 18 sampled residents and one resident (Resident #44) outside the sample. The facility census was 86. Review of the facility policy titled, Bed Hold, dated 04/01/22, showed: - It will be the policy of this facility to provide residents with bed hold policies upon admission to the facility and at the time of transfer (i.e. when transferring to hospital or going on therapeutic leave) in accordance with federal and state regulations; - The initial bed hold policy should be provided to the resident/responsible party as soon after admission as possible when completing the admission packet to the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify, assess, and provide supportive interventions for one resident (Resident #78) with a diagnosis of post traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event) out of three sampled residents. The facility's census was 86. Review of the facility's policy titled, Mental and Psychosocial Adjustment Services, dated 04/01/22, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the nurse aides (NAs) an annual individual performance review or evaluation and failed to provide regular in-service education based on these reviews for two certified nursing assistants (CNAs) (CNA A and CNA B). The facility census was 86. Review of the Facility Assessment Tool, dated 04/10/24, showed: - A facility must develop, implement, and maintain an effective training program for all new and existing staff; - In-service training must address areas of weakness as determined in NA's performance reviews; - In-service training may address the special needs of residents as determined by the facility staff. 1. Review of CNA A's employee file showed: - A hire date of 09/15/08; - No documentation of an annual performance review or evaluation; [...]

Inspectors wroteBased on interview and record review, the facility failed to attempt a gradual dose reduction (GDR) for two residents (Residents #21 and #36) out of five sampled residents. The facility's census was 86. Review of the facility policy titled, Pharmacist Recommendations, dated 04/01/22, showed: - It will be the policy of this facility to provide pharmacist services to meet the needs of the residents through monthly regimen review (MRR) and properly addressing recommendations per federal and state guidelines; - The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. This review must include a review of the resident's medical chart. An electronic medication regimen review will be performed within 72 hours of admission for newly admitted residents, or as soon as reasonably possible; [...]

Inspectors wroteBased on interview and observation, the facility failed to ensure bedtime snacks had been offered to all residents at bedtime. This had the potential to affect all residents in the facility. The facility census was 86. Review of the facility policy titled, Nutrition and Hydration Assistance, dated 04/01/22, showed: - Additional sources of nourishment should/may include provision of snacks; - Staff will make provision for appropriate snacks as requested or ordered by the physician. Review of the facility policy titled, Provide Diet to Meets Needs of Each Resident, dated 04/01/22, showed: - The facility would provide the services of a Registered Dietitian Nutritionalist or designee to participate in the interdisciplinary care planning team and assure that the nutritional needs of individuals living in the facility are met. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. The facility failed to ensure that foods were kept covered while waiting to be served and had policies and procedures in place for food brought in from outside the facility. These practices had the potential to affect all residents who are served food from the kitchen. The facility census was 86. Review of the facility policy titled,Food Delivery and Storage, dated 10/01/23, showed: - It will be the policy of this facility that foods shall be received and stored in a manner that complies with safe food handling practices; - Dietary/Food Services, or other designated staff, will maintain clean food storage areas at all times; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain or implement a policy regarding the acceptance, usage, and storage of foods brought into the facility for residents by food delivery services, family, and/or other visitors, to ensure the food's safe and sanitary handling, storage, and consumption. This deficient practice had the potential to affect all residents who ate food brought in by visitors. The facility census was 86. Review of the facility form titled, Resident Responsibilities and Rules, Appendix 4, undated, showed: - Food may be brought into our facility; - It must be kept in airtight containers; - Because of diet restrictions, nursing staff should be made aware of any food brought into the facility; - Should food need to be monitored, it will be kept in a designated room; [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain essential equipment in a safe and operable working condition. This deficient practice had the potential to affect all residents. The facility census was 86. The facility did not provide a policy for equipment maintenance. Review of the following invoices showed: - On 12/16/24, an invoice for a laundry washer was serviced but no details of actions taken; - On 12/30/24, an invoice for a laundry washer was serviced with a valve and hose replaced. Observation on 04/02/25 at 9:40 A.M. of the laundry room, showed: - Three commercial laundry washing machines; - Two of the machines were covered in dust and debris and not in use; - The third machine was running a load of laundry. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide a safe and functional environment for the residents by allowing items to be stored on top of the overbed light fixtures for residents in three rooms. Storing items on the overbed light creates a hazard of the items falling on the resident below, and does not utilize the light fixtures as intended. The deficient practice had the potential to affect all residents and staff in the facility. The facility census was 86. The facility did not provide a policy regarding storing items on the overbed light fixtures. 1. Observation on 03/03/25 at 2:39 P.M., of Room B 5-1 showed a large picture in a wooden frame on the light above the resident's bed. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct at least twelve hours of nurse aide (NA) in-service education per year. This affected two Certified Nurse Assistants (CNAs) (CNA A and CNA B) out of two sampled CNAs. The facility's census was 86. The facility did not provide a policy regarding annual NA education. 1. Review of CNA A's employee file showed: - A hire date of 09/15/08; - A total of 2 hours 50 minutes of annual in-service training completed for the time frame of September 2023 through September 2024; - The facility failed to provide at least 12 hours of in-service education for September 2023 through September 2024. 2. Review of CNA B's employee file showed: - A hire date of 06/10/21; - A total of 5 hours 45 minutes of annual in-service training for June 2023 through June 2024; [...]

Inspectors wroteBased on observation and interview, the facility failed to promote resident independence and dignity while dining when staff served the noon meal on disposable dishware. The facility census was 86. Review of the facility policy titled, Resident Rights, Dignity and Visitation Rights, dated 04/01/22, showed: - It will be the policy of this facility that employees shall treat residents with kindness, respect, and dignity. The facility promotes the exercise of rights for each resident, including any who face barriers (such as communication problems, hearing problems and cognition limits) in the exercise of these rights. The facility will ensure that the resident can exercise his/her rights without interference, coercion, discrimination, or reprisal from the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an on-going program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident. This practice affected five residents (Residents #13, #21, #22, #24, and #31) out of 18 sampled residents and could potentially affect all residents. The facility census was 86. Review of the facility policy titled, Activities, dated 04/01/22, showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide consistent resident care for activities of daily living (ADLs) when the residents went an extended amount of time without showers for three residents (Resident #1, #2, and #3) out of 6 sampled residents. The facility's census was 92. The facility did not provide a policy regarding showers. 1. Review of Resident #1's medical record showed: - An admission date of 07/26/24; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to properly maintain the temperature of hot food at or above 120 Degrees Fahrenheit (°F) for 12 residents (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, and #12), out of 12 sampled residents, at the time of meal service and failed to implement a system to monitor food temperatures at the time of service. Failure to maintain foods at the proper temperature has the potential to affect all residents receiving meal trays. The facility's census was 94. Review of the Missouri Food Code for the Food Establishments of the State of Missouri, provided by the facility and dated June 3, 2013, showed: - Refrigerated, potentially hazardous food shall be at a temperature of 41 degrees Fahrenheit or below when received; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician's orders for one resident (Resident #1) out of eleven sampled residents when Resident #1 did not receive five doses of his/her seizure medication. The facility census was 87. Review of the facility's policy titled, Medication Administration, dated 09/01/22, showed: - Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards, in a manner to prevent contamination or infection; - Correct any discrepancies and report to the nurse manager; - The policy did not address what to do if the medication was not available. 1. Review of Resident #1's medical record showed: - admission date of 06/19/24; [...]

Inspectors wroteThe facility failed to protect the rights of four of six sampled residents (Residents #1, #2, #3 and #4) by establishing a practice of revoking the resident's right to temporarily leave the facility by a physician's order for residents who are their own person, in response to that resident not following the rules established in the newly updated admission policy. The facility census was 86. Review of the facility's policy titled, Possession and/or use of Illegal Substances, Marijuana, and Alcohol, dated 2/1/2023 and updated 6/5/2024, showed: - If the facility staff identifies items or substances that pose risks to residents' health and safety and are in plain view, staff will confiscate them and alert their immediate supervisor; [...]

Inspectors wroteThe facility failed to protect the rights of one of the six sampled residents (Resident #1) by prohibiting the visitation of a family member based on the facility's assumption that the family member was in possession of Marijuana. The census was 86. Record review of the policy on Possession and/or use of Illegal Substances, Marijuana, and Alcohol dated 2/1/2023 and updated 6/5/2024, showed: - If the facility staff identifies items or substances that pose risks to residents ' health and safety and are in plain view, they will confiscate them and alert their immediate supervisor; - The staff will notify resident ' s attending physician if resident if found with or suspected to be displaying signs/symptoms or being under the influence of illegal substance, alcohol, and /or marijuana to determine necessary interventions and/or medications/treatments they may need to hold; [...]

Inspectors wroteBased on record review and interview, the facility failed to obtain written authorization from the resident and/or financial guardian for money withdrawn for two residents (Resident #6 and #7) out of a sample of 14. Additionally, the facility also failed to allow residents access to resident funds on an ongoing basis. This had the potential to affect all residents the facility managed funds for. The facility census was 86. 1. Record review of the facility maintained Resident Trust Ledger for the period 07/01/24 through 08/19/24, showed the following withdrawal from Resident #6's account: Date Amount Description 07/30/24 $50.00 Resident Advance Cash Record review on 08/19/24 of the facility maintained paperwork for Resident #6's Resident Trust Ledger, showed Resident #6's handwritten name with no written authorization by Resident #6 and/or financial guardian for the listed withdrawal. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe smoking interventions for two residents (Resident #48 and #336) out of four sampled residents who smoke and four residents (Resident #24, #73, #76, and #80) outside the sample. The facility census was 83. Review of the facility's policy, Resident Smoking, revised 03/03/22, showed: - This facility provides a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and non-smoking residents; - Any resident who is deemed safe to smoke, with or without supervision, will be allowed to smoke in designated smoking areas (weather permitting), at designated times, and in accordance with his/her care plan; [...]

Inspectors wroteBased on observation and interview, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These practices had the potential to affect all residents who are served food from the kitchen. The facility census was 83. Review of the facility's policy, Food Safety Requirement, dated 09/01/21, showed: - It is the policy of this facility to procure food from sources approved or considered satisfactory by the federal, state, and local authorities; - Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety. 1. Observation on 06/04/24 at 12:14 P.M., 06/05/24 at 12:14 P.M. and on 06/06/2024 at 10:45 P.M. of the walk-in refrigerator showed dirt and debris in the bottom of the refrigerator. 2. Observation on 06/04/24 at 12:14 P.M., 06/05/24 at 12: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide documentation of on-going assessments, monitoring, and communication between the facility and the dialysis (a process for removing waste and excess water from the blood) center for one resident (Resident #14) out of one sampled resident. The facility's census was 83. Review of the facility's policy, Dialysis Care Guidelines, revised 03/15/24, showed: - Communication between the dialysis provider and center staff should included written communication that includes daily weights, changes in condition or mood, response to treatment, and evaluation of the vascular site; - Whether resident receives hemodialysis out of center or receives dialysis in house, communication is essential for continuity of care; - Be cognizant of medications ordered and timing of administration; [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the dumpsters were closed at all times and maintained to keep pests out and to keep the garbage contained in the dumpster. The facility census was 83. The facility did not provide a sanitation policy. Observations of the dumpster, located in front of the facility, showed: - On 06/06/24 at 8:05 A.M., the dumpster with the lid opened with visible bags and other miscellaneous items; - On 06/6/24 at 1:00 P.M., the dumpster with the lid opened with visible bags and other miscellaneous items; - On 06/6/24 at 4:10 P.M., the dumpster with the lid opened with visible bags and other miscellaneous items; - On 06/07/24 at 8:15 A.M., the dumpster with the lid opened. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices to prevent the development and transmission of infection for one resident (Resident #336) out of 18 sampled residents. The facility's census was 83. Review of the facility's policy, Infection Prevention and Control Program, revised 05/15/23, showed: - All reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment; - All staff shall demonstrate competence in relevant infection control practices; - Direct care staff shall demonstrate competence in resident care procedures established by our facility; - Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to control the fly population in the facility. This practice had the potential to affect all residents. The facility census was 83. Review of the facility's policy titled, Pest Control Program, revised 09/01/22, showed an effective pest control program is defined as measures to eradicate and control and contain common household pests (bed bugs, lice, roaches, ants, mosquitos, flies, mice, and rats). Review of the facility's Policy Explanation and Compliance Guidelines, dated 09/21/21 and revised on 09/01/22, showed: - Facility will maintain a written agreement with a qualified outside pest service to provide comprehensive pest control services on a regular and scheduled basis; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to provide a safe and sanitary environment to help prevent the potential spread of COVID-19 (an acute respiratory illness in humans caused by the coronavirus, SARS-CoV-2) and other infections, when staff failed to follow acceptable infection control practices for COVID-19. The facility failed to separate six residents (Resident #1, #2, #3, #4, #5, and #6) who tested positive for COVID-19 from six residents (Resident #7, #8, #9, #10, #11 and #12) who had tested negative for COVID-19, which placed the residents at an increased risk of contracting COVID-19 due to prolonged exposure. The facility census was 85. The Administrator, Director of Nursing, and Assistant Director of Nursing/Infection Preventionist were notified on 10/13/23 at 04:00 P.M. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This potentially affected all residents. The facility census was 94. Record review of the facility's General Sanitation of the Kitchen policy, revised July 2019, showed: - Food and nutrition services staff will maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule; - Cleaning and sanitation tasks for the kitchen will be outlined in a written cleaning schedule; - Tasks will be assigned to be the responsibility of specific positions; - Frequency of cleaning for each task will be defined; - Employees will be trained on how to perform cleaning tasks; - On the cleaning schedule, employees will initial and date tasks when completed. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean and comfortable homelike environment. The facility census was 94. Record review of the facility's Preventative Maintenance Program policy, revised November 2017, showed: - A Preventative Maintenance Program shall be developed and implemented to ensure the provisions of a safe, functional, sanitary and comfortable environment for residents, staff and the public; - The Maintenance Director will be responsible for developing and maintaining a schedule for maintenance services to ensure that the buildings, grounds, and equipment will be maintained in a safe and operable manner; - The Maintenance Director shall assess all aspects of the physical plant to determine if preventative maintenance will be required; [...]

Inspectors wroteBased on interview and record review, the facility failed to send a copy of the notice for transfer or discharge to the resident and or the resident's representative, for six residents (Resident #15, #16, #17, #36, #66 and #70) out of seven sampled residents. The facility's census was 94. Record review of the Transfer and Discharge Policy, dated 9/22/22, showed: - Emergency Transfers/Discharges - initiated by the facility for medical reasons to an acute care setting such as a hospital, for the immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified); - Obtain physician's orders for emergency transfer or discharge, stating the reason the transfer or discharge shall be necessary on an emergency basis; - The original copies of the transfer form and the Advance Directive accompany the resident. Copies will be retained in the medical record; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to utilize proper technique during catheter (a tube inserted into the urinary bladder to drain the bladder) care for three residents (Resident #13, #41, and #66) out of three sampled residents, incontinent care for one resident (Resident # 25) out of two sampled residents, and wound care for one resident (Resident #13) out of a two sampled residents. The facility failed to maintain infection control practices for six residents (Resident #1, #9, #42, #44, #80, and #196 ) out of eight sampled residents during medication administration when facility staff did not wash or sanitize hands or touched medication with bare hands. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the handrails on the A, C, D and E Halls were properly maintained. This deficient practice had the potential to affect all residents on these halls. The facility census was 94. Record review of the facility's Preventative Maintenance Program policy, revised November 2017, showed: - A Preventative Maintenance Program shall be developed and implemented to ensure the provisions of a safe, functional, sanitary and comfortable environment for residents, staff and the public; - The Maintenance Director will be responsible for developing and maintaining a schedule for maintenance services to ensure that the buildings, grounds, and equipment will be maintained in a safe and operable manner; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff treated residents with dignity and in a respectful manner by leaving one resident (Resident #25) out of 20 sampled residents exposed after staff left the resident's room. The census was 94. Record review of the facility's Resident Rights policy, dated 9/1/21, showed: - The resident with the right to be treated with respect and dignity; - Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits and meetings. 1. Observation of Resident #25 showed: - On 11/29/22 at 2:39 P.M., the resident lay in bed with the door open, in a shirt and brief, and uncovered; - On 11/20/22 at 3:45 P.M., the resident lay in bed with the door open, in a shirt and brief, and uncovered; - The resident visible from the hallway. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a physician's order for the code status (the type of emergent treatment a person would or wouldn't receive if their heart or breathing were to stop) for two residents (Resident #26 and #52) out of 20 sampled residents. The facility census was 94. Record review of the facility's Residents' Rights Regarding Advance Directives (a written statement of a person's wishes regarding medical treatment) policy, revised on [DATE], showed: - The facility will support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive; - On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide written information to the resident and/or the resident's legal representative of their bed hold policy at the time of transfer to the hospital for two residents (Resident #36 and #66) out of seven sampled residents. The facility's census was 94. Record review of the facility's Bed Hold policy, revised April 2017, showed: - The bed hold policy will be reviewed with the resident, designated family member, and/or the resident's legal representative; - Before a resident will be transferred to a hospital or goes on therapeutic leave, a written Bed Hold policy will be given to the resident, designated family member, and/or the resident's legal representative; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to document a complete and accurate Minimal Data Set (MDS), a federally mandated assessment to be completed by the facility, for three residents (Resident #16, #46, and #86) out of 20 sampled residents. The facility census was 94. Record review of the facility's Resident Assessment - Resident Assessment Instrument (RAI) policy, revised 8/18/2022, showed: - This facility makes a comprehensive assessment instrument of each resident's needs, strengths, goals, life history and preferences using the RAI specified by the Centers for Medicare and Medicaid Services (CMS). - The results of the assessment will be used to develop, review, and revise the resident's comprehensive care plan. 1. Observation of Resident #16 on 11/29/22 at 2:51 P.M. showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan consistent with the resident's specific conditions, needs, and risks within 48 hours of admission which included the minimum healthcare information necessary to provide care for one resident (Resident #52) out of five sampled residents. The facility's census was 94. Record review of the facility's Baseline Care Plan policy, dated 6/2/22, showed: - The facility will develop and implement a baseline care plan for each resident; - The care plan will be developed within 48 hours of admission; - It will include the minimum healthcare information necessary to properly care for a resident including, but not limited to the initial goals based on admission orders, medical provider orders, dietary orders, therapy services, and social services; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a care plan with specific interventions tailored to meet individual needs for two residents (Resident #9 and #55) out of 20 sampled residents. The facility census was 94. Record review of the facility's Care Plan policy, dated 6/2/22, showed: - The facility will develop and implement a comprehensive person centered care plan for each resident; - The care plan will be consistent with the resident rights, professional standards of practice, medical provider orders and resident's goals and preferences; - It will include measurable objectives and timeframes to meet a resident's special medical, nursing, mental and psychosocial needs that will be identified in the resident's comprehensive assessment. 1. Record review of Resident #9's medical record showed: - An admission date 8/5/22; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain physician orders for five residents (Resident #9, #16, #17, #26 and #53) out of 20 sampled residents. The facility census was 94. Record review of the facility's Oxygen Administration policy, dated 5/4/22, showed oxygen to be administered under orders of a medical provider, except in cases of emergency. 1. Record review of Resident #9's medical record showed: - admission date 8/5/22; - Diagnoses of congestive heart failure (CHF) (a condition in which the heart doesn't pump blood as well as it should) and chronic obstructive pulmonary disease (COPD) (a group of lung diseases that block airflow and make it difficult to breathe). Record review of the resident's Physician Order Sheet (POS), dated 11/30/22, showed no physician's order for oxygen. Observations of the resident showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide consistent resident care for activities of daily living (ADL's) when the residents went an extended amount of time without showers for four residents (Resident #28, #55, #66, and #71) out of 20 sampled residents, and one resident (Resident #1) outside the sample. The facility census was 94. Record review of the facility's Resident Showers policy, revised 5/4/22, showed: - The facility will assist residents with bathing to maintain proper hygiene and help prevent skin issues; - The policy did not address how often showers to be given. Record review of the facility's Bed Baths policy, revised 11/10/22, showed: - Document the procedure. 1. Record review of Resident #1's medical record showed: - An admission date of 9/16/16; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure treatment and care of standard of practice by not following the bowel regimen policy for one resident (Resident #55) out of 20 residents. The facility census was 94. Record review of the facility's Bowel Regimen policy, revised 4/5/2022, showed: - Will monitor the residents bowel movements (BM) and provide clinical best practice interventions as needed for a resident to have regular bowel movements; - Resident BM's will be evaluated and documented daily; - If a resident does not have a BM for 72 hours, the clinical team shall be alerted; - If the resident has any as needed (PRN) orders for bowel elimination assistance, it should be followed; - If the resident has no PRN order, notify the physician to obtain an order; - Monitor the resident's response to administration of bowel elimination assistance; [...]

Inspectors wroteBased on interview and record review, the facility failed to reposition two residents (Resident #13 and #26) out of two sampled residents who were identified as at risk for pressure ulcers (damage to the skin and/or underlying tissue as a result of pressure). The facility also failed to follow physician ordered wound care orders for one resident (Resident #13) out of two sampled residents. The facility census was 94. Record review of the facility's Pressure Injury (damage to the skin and/or underlying tissue as a result of pressure) Prevention and Management policy, revised on 3/3/22, showed: - The purpose will be to prevent avoidable pressure injuries and the promotion of healing existing pressure injuries; - Intervention will be based on specific factors identified in the risk assessment, skin assessment and any pressure injury assessment; [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to ensure residents with limited range of motion (ROM) received appropriate treatment and services to increase their ROM and/or prevent a further decrease in their range of motion. The facility staff failed to perform restorative services as recommended by the occupational therapist (OT) for one resident (Resident #36) out of 5 sampled residents. The facility census was 94. Record review of the facility's Restorative Nursing Program (RNP) policy, revised, 5/4/2022, showed: - The facility will provide maintenance and restorative services to maintain or improve a resident's abilities to the highest practicable level; - Cognitive and physical functioning of all residents will be assessed in accordance with the facility's assessment protocols; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide proper incontinent care for two residents (Resident #25 and #26) out of two sampled residents. The facility census was 94. Record review of the facility's Perineal Care policy, revised on 5/4/22, showed: - If the perineum should be grossly soiled, turn the resident on his/her side, remove any fecal material with toilet paper, then remove and discard. Cleanse the buttocks and anus, front to back, vagina to anus in females, scrotum to anus in males, using a separate washcloth or wipes. Thoroughly dry; - Reposition the resident in a supine (lying face up) position. Change gloves if soiled and continue with perineal care; - Remove gloves and discard, perform hand hygiene. 1. Record review of Resident #25's medical record showed: - An admission date of 9/26/15; [...]

Inspectors wroteBased on interview and record review, the facility failed to follow physician's orders and the facility policy on getting weights on new admissions to monitor the nutritional status for two residents (Resident #54 and #55) out of three sampled residents. The facility census was 94. Record review of the facility's Weight Monitoring policy, revised, 6/2/2022, showed: - Weight can be a useful indicator of nutritional status; - Significant unintended changes in weight may indicate a nutritional problem; - A weight monitoring schedule will be developed upon admission for all residents; - Weights should be recorded at the time obtained; - Newly admitted residents should have weights monitored weekly for four weeks; - If clinically indicated, weights should be monitored daily; - All other residents' weights should be monitored monthly. 1. Record review of Resident #54's medical record showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide documentation of ongoing assessments, monitoring, and communication between the facility and the dialysis (a process for removing waste and excess water from the blood) center for two residents (Resident #17 and #66) out of two sampled residents. The facility census was 94. Record review of the facility's Hemodialysis (dialysis) policy, revised March 3, 2022, showed: - The facility will assure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice, including an ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the nurse staffing data with all the required components in a clear and readable format. The facility's census was 94. Record review of the facility's Nurse Staffing Posting Information policy, dated 6/2/22, showed: - The daily staffing sheet will be posted on a daily basis and will contain the facility name, the current date, the current resident census, the total number and the actual hours worked by the licensed and unlicensed staff directly responsible for resident care per shift; - The facility will post daily and at the beginning of each shift. Observations of the nurse staffing information posted on the wall across from the nurse's station showed; - On 11/29/22 at 2:03 P.M., the posted nurse staffing information, dated 11/23/22, with no information for 11/29/22; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store medications in a safe and effective manner. The facility census was 94. Record review of the facility's Medication Administration policy, revised 4/7/22, showed: - Identify the expiration date; - If medication expired, notify the nurse manager; - Staff to observe the resident consumption of medications. 1. Observation on 12/2/22 at 8:50 A.M., of a medication pass showed: - Licensed Practical Nurse (LPN) G provided Resident #44 with an inhaler while the resident sat in the the therapy room; - While the resident self-administered his/her inhaler, LPN G left the therapy room and closed the therapy room door, went to the medication cart further down the hallway, obtained a blood pressure cuff, and returned to the therapy room; - LPN G gave the resident his/her oral medication in a pill cup to hold; [...]

Inspectors wroteBased on interview and record review, the facility failed to document accurate immunization status, provide information and education to each resident or the resident's representative of the influenza vaccine (a vaccine used to protect against influenza), pneumococcal vaccines (a vaccine used to protect against pneumonia bacteria) for two residents (Residents #16 and #26) out of five sampled residents. The facility's census was 94. Record review of the facility's Patient Immunization policy, revised February 2022, showed: - Influenza recommend annually for all residents; - Pneumococcal recommended for resident 65 years and older. Record review of the facility's Immunization Recommendations for Residents of Long-Term Care Facilities Immunization Manual, undated, showed: - Influenza recommended annually for all residents; [...]