Ascend at Aurora

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide all residents with functioning call lights system when call lights for four resident rooms affecting three residents (Resident #1, #3, and #4) did not sound at the door nurses' station and when the call light for one resident (Resident #1) did not have a call light cover present. The facility census was 74. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to report all allegations of abuse timely when staff failed to report an allegation of resident-to-resident abuse involving two residents (Resident #1 and Resident #2) immediately to administration and failed to the Department of Health and Senior Services (DHSS) within the required two hours of the facility staff becoming aware of the allegation. The facility census was 77. Review of the facility's policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, reviewed 10/2025, showed the following:-Residents have the right to be free of abuse. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that an allegation of possible abuse was thoroughly and immediately investigated when a staff member received an allegation of abuse regarding two residents (Resident #1 and #2) and staff failed to complete an immediate written investigation. The facility census was 77. Review of the facility's policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, reviewed 10/2025, showed the following:-Residents have the right to be free of abuse. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure all residents who were trauma survivors receive trauma-informed care when nursing staff was not informed about one resident's (Resident #1) past trauma as it could relate to care and failed to add trauma-informed care interventions to the resident's care plan. The facility census was 77. Review of the facility's policy titled, Trauma-informed Care Policy and Procedure, dated 03/11/26, showed the following:-The facility shall provide culturally competent, trauma-informed care to residents who are trauma survivors. [...]

Inspectors wroteBased on interview and record review, the facility failed to inform the resident representative of a change in condition for one resident (Resident #90) when the resident had a fall that resulted in an injury. The facility census was 73. Review of the facility's policy titled, Change in Resident's Condition or Status, updated December 2025 showed the following: -The facility shall promptly notify the resident, their healthcare provider, and representative of changes in the resident's physical, mental, or psychosocial condition.-Unless otherwise instructed by the resident, the Nurse Supervisor/Charge Nurse will notify the resident's family or representative when:-The resident is involved in any accident or incident that results in an injury including injuries of an unknown source.1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents received treatment and care in accordance with professional standards of practice when the facility failed to administer medications as ordered and failed to notify the physician of missed medications, for one resident (Resident #13). The facility census was 73. Review of facility policy titled Medication Administration, revised August 2025, showed the following: -Medications will be administered in a safe and effective manner. The guidelines in this policy apply to all medications. Nursing policies developed by the facility may supersede the procedures outlined in this policy; -Notify the attending physician and/or prescriber of: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received care consistent with professional standards of practice to promote prevention and healing of pressure ulcers (refers to localized damage to the skin and/or underlying tissue usually over a bony prominence) pressure ulcers when the facility failed to timely assess, document, and implement treatment and monitoring of a pressure ulcer for two resident (Resident #3 and #4). The facility census was 53. Review of the facility policy titled Skin Integrity- Pressure and Non-Pressure reviewed 06/30/25, showed the following information:-Pressure and other ulcers will be assessed and measured at least weekly by a licensed nurse and documented;-A skin condition assessment and pressure ulcer risk assessment will be completed at the time of admission. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received and the facility provided food to accommodate resident allergies when the facility failed to ensure residents were not served foods they were allergic to, failed to care plan resident allergies, and failed to enter resident allergies into the physician orders for one resident (Resident #1) out of 6 sampled residents. The facility census was 53. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect residents from misappropriation of property when staff could not account for two residents' (Resident #1 and #2) cards of controlled medications (narcotics) that had been in the possession of the facility. The facility census was 60. The Administrator and former Director of Nursing (DON) were notified on 11/23/25 of the missing medications. The facility completed an audit of resident medications, completed in-servicing of licensed staff who were involved in medication pass and medication storage, and notified families and physicians of the missing medications. The noncompliance was corrected 11/26/25. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure all allegations of misappropriation of property were reported within 24 hours to the State Survey Agency (Department of Health and Senior Services-DHSS) when staff failed to report timely when they discovered two missing cards of narcotics for two residents (Resident #1 and Resident #2). The facility census was 60. The Administrator and former Director of Nursing (DON) were notified on 11/23/25 of the missing medications. It was discovered on 11/26/25 are report to DHSS had not been made. The facility completed in-servicing of staff and audits of records. The noncompliance was corrected on 11/26/25. [...]

Inspectors wroteBased on observation and interview, the facility failed to protect each resident's right of self-determination when the facility staff failed to provide routine showers per reasonable preferences of each resident and as care planned for three sampled residents (Residents #1, #2, and #3). The facility census was 54. Review of the facility policy, Your Rights and Protections as a Nursing Home Resident, undated, showed the following:-The resident has the right to be treated with dignity and respect, as well as make to make hi/s/her own schedule and participate in the activities he/she chooses;-The resident has the right to make a complaint to the staff of the nursing home, or any other person, without fear of punishment. The nursing home must address the issue promptly. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a complete infection prevention and control program when the facility failed to ensure staff posted appropriate signage and failed to ensure staff wore person protective equipment (PPE) in accordance with the Centers for Disease Control (CDC) guidelines for residents subject to enhanced barrier precautions (EBP - precautions for use during high-contact resident care activities for residents infected with a multidrug-resistant organism (MDRO-microorganisms that are resistant to one or more classes of antimicrobial agents) or any resident who has a chronic wound and/or indwelling medical device) for one resident (Resident #3), of three sampled residents, who had a indwelling medical device. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #48), who is non-verbal and dependent on staff for all personal needs and mobility, was free from mental abuse by staff when one staff member, Certified Nurse Aide (CNA) S, purposely made comments to the resident to upset him/her. The resident was visually upset when discussing the CNA and the comments made to him/her, including becoming red faced, teary eyed, reaching out his/her arm and grunting. A sample of 26 residents was reviewed in a facility with a census of 60. On 2/8/24, SLCR completed a complaint investigation at the facility regarding an allegation of the resident not being treated with dignity and was unable to verify deficient practice occurred. A reinvestigation began during the recertification survey. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents remained free of significant medication errors when staff administered a fentanyl patch (a narcotic patch placed on the skin to treat moderate to severe pain) and hydrocodone-APAP (narcotic that is used for relief of severe pain) to one resident (Resident #162) without orders, resulting in significant side effects and hospitalization. A sample of 26 residents was reviewed in a facility with a census of 60. The Administrator was notified on 04/11/24, at 2:28 P.M., of an Immediate Jeopardy (IJ) which began on 01/31/24. The resident went to the hospital and did not readmit to the facility. The IJ was removed on 04/12/24 as confirmed by surveyor onsite verification. Review of the facility's policy titled Medication Administration, dated 07/12/13, showed the following: [...]

Inspectors wroteBased on record review and interview, the facility failed to designate a registered nurse (RN) to serve as the Director of Nursing (DON) on a full time basis. The facility census was 60. Review of the facility's document titled, Director of Nursing Services job description showed the following: -The primary purpose of the job position is to plan, organize, develop and direct the overall operation of the nursing service department in accordance with current federal, state, and local standards, guidelines, and regulations that govern the facility, and as may be directed by the Administrator and the Medical Director to ensure that the highest degree of quality care is maintained at all times; -The Director of Nursing Services (DON) is delegated the administrative authority, responsibility, and accountability necessary for carrying out the assigned duties. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in a manner to protect it from potential contamination when staff failed to date and label stored food in refrigerators; failed to keep non-food contact surfaces clean and free of debris; and failed to sanitize dishes in the three vat sink at the minimum manufacturer's requirements. The facility's census was 60. 1. Review of the facility's policy titled, Food Storage - Refrigeration, undated, showed all leftovers shall be labeled and dated with expiration dates. Observation on 04/07/24, at 2:42 P.M., of the reach in refrigerator showed the following: -One individual serving dish of peach pie not covered, labeled, or dated; -One cheese sandwich on a plate, covered and not dated. Observation on 04/07/24, at 2:51 P.M., of the walk-in refrigerator showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to review and update the comprehensive facility assessment annually, in accordance with all applicable Federal requirements. Failure to review and update the comprehensive facility assessment annually could delay the services needed to care for the residents in day-to-day operations and in emergencies. This failure could affect all facility occupants. The facility census was 60. Review showed the facility did not provide a policy regarding the facility assessment. 1. Review of the facility's assessment, showed the following: -Staff completed the facility assessment in 2020; -Staff did not document review of the facility assessment since 2020. During an interview on 04/12/24, at 2:15 P.M., the Administrator said the following: -She began the position on 04/05/24; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective and complete infection control program when staff failed to follow the facility's policy to monitor and prevent the development 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's water system. The facility also failed to update policies, educate staff, and implement policies related to Enhanced Barrier Precautions for six residents (Resident #110, #47, #160, #20, #161, and #24) out of a sample of 26 residents. The facility census was 60. 1. [...]

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. This failure could potentially place all residents at risk of infection. The facility census was 60. Review of the facility's policy, titled 'Infection Prevention and Control Program', dated 2019, showed the following: -The primary mission is to establish and maintain an Infection Prevention and Control Program (IPCP) designed to provide a safe, sanitary and comfortable environment and to help the development and transmission of communicable diseases and infections; [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain a facility temperature range of 71 to 81 degrees Fahrenheit (F) and at a comfortable level of the residents in resident rooms and common areas accessible to residents affecting ten residents (Residents #160, #14, #52, #25, #50, #32, #31, #41 ,#35, and #45) out of a sample of 26 residents. The facility census was 60. Review showed the facility did not provide a policy regarding facility heating and cooling system or monitoring of facility temperature for resident comfort. 1. Review of the National Weather Service (website weather.gov) showed on 04/07/24 the high temperature measured 71.6 degrees F. 2. Review of Resident #160's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by the facility), dated 04/08/24, showed the following: -admission date of 03/27/24; -Cognitively intact; [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their abuse prevention policy of screening all staff at hire when the facility failed to request a Criminal Background Checks (CBC) or Family Care Safety Register (FCSR - a database that can provide CBC along with other background checks) check prior to one staff member's (Licensed Practical Nurse (LPN) D) contact with residents. A sample of 10 hired employees was reviewed in a facility with a census of 60. Review of the facility's Abuse Prevention Policy, dated 2021, showed the following: -The facility's abuse prohibition program includes the following seven components: screening, training, prevention, identification, investigation, protection and reporting/response; -Screening: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for all residents when staff failed to care plan oxygen use for one resident (Resident #2), failed to care plan smoking safety for one resident (Resident #160), and failed to care plan wound care for one resident (Residents #259). A sample of 26 residents was reviewed in a facility with a census of 60. Review of facility's policy titled, Care Planning - Interdisciplinary Team, dated 02/2021, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to care plan use of side rails and failed to obtain informed consent for use of side rails for two residents (Resident #6 and #12), and failed to complete gap measurements for installed side rails for three residents (Resident #6, #12, and #23) of a sample of four residents. The facility census was 60. Review of the facility's policy titled, Proper Use of Side Rails, revised December 2016, showed the following: -The purpose of these guidelines is to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms; -Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of resident's; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared in a form to meet residents' needs when staff failed to prepare pureed food to the proper consistency in accordance with professional standards for one resident (Resident #26) out of four residents on a pureed texture diet. The facility census was 60. Review of the facility's policy titled, Meal production - Menu, undated, showed pureed food should not be thinner than pudding or thicker than mashed potatoes. 1. Review of Resident #26's face sheet (resident's information at a quick glance) showed the following: -admission date of 04/03/20; -Diagnoses included senile degeneration of the brain (older individuals who suffered from cognitive decline, particularly memory loss), anxiety, and vitamin A deficiency. [...]

Inspectors wroteBased on record review and interview, 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 the transfer, for two residents (Resident #21 and #160), out of a sample of 26 residents. The facility census was 60. Review of the facility's document titled, Notification of Transfer or Discharge, undated, showed the following fields to be completed by facility staff: -Date of transfer, date of notice, resident name, and representative name; -Missouri Ombudsman office, address, and phone number; -You are hereby notified of our intent to transfer or discharge the above named resident for the following reason; -Name and address of location which resident will be transferred or discharged to; -Notice to resident regarding right to appeal transfer or discharge; [...]

Inspectors wroteBased on interview and record review, the facility failed to give information to the resident and/or resident's representative of the facility's bed hold policy when two residents (Residents #21 and #160) were transferred to the hospital, out of a sample of 26 residents. The facility census was 60. Review of the facility provided policy, dated February 2014, Bed Hold Policy & Agreement Form, showed the following: -To establish policy and procedure for facility to notify the resident and/or responsible party of the Bed Hold Policy and Agreement to Pay Charges for Bed Hold; -The bed hold agreement is to be obtained for each occurrence - hospital or therapeutic leave; -When hospital or therapeutic leave is reported on the midnight census, the business office will notify the resident and/or responsible party to sign the bed hold agreement; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all dialysis residents received services consistent with professional standards of practice when staff failed to routinely communicate and collaborate with the dialysis (a process of filtering and removing waste products from the bloodstream when the kidneys can no longer sufficiently do so) center after appointments for one resident (Resident #47) out of a sample of two residents. The facility census was 60. Review of the facility's policy titled Dialysis Communication, dated 02/2021, showed the following: -It is the policy of the facility to communicate openly and effectively with any provider of dialysis for a resident of the facility; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all residents received behavioral health care and services to maintain the highest practical psychosocial well-being when the facility failed to care plan and implement resident specific interventions for one resident (Resident #259) who exhibited signs and symptoms of depression. The facility failed to have social services follow-up with the resident when the resident expressed signs of possible depression. The facility census was 60. Review showed the facility did not provide a behavioral health policy. 1. Review of Resident #259's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 03/18/24; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure as needed (PRN) orders for psychotropic medications were limited to 14 days when one resident (Resident #9) had an ongoing order for a psychotropic medication with no physician review and justification. The facility census was 60 residents. Review of the facility's policy Psychotropic Medication Use, dated 02/2021, showed the following: -Residents will only receive psychotropic medications when necessary to treat specific conditions which they are indicated and effective; -Gradual dose reductions of psychotropic medications will be done as outlined per federal regulations. (The policy did not address requirements for psychotropic PRN orders.) 1. Review of Resident #9's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 01/05/23; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a sanitary environment when the kitchen floors in a clean manner when the floors and a drain in front of the tilt skillet were not cleaned. The facility census was 58. Record review of the Nutrition Services for Department Sanitation guideline, revised on January 2021 showed: -The purpose was to ensure a clean and sanitary work environment; to promote and protect food safety; and to maintain compliance with Federal, State, and Local guidelines and regulations governing food sanitation and safety;. -Sanitation shall be maintained in a manner to support procedures for Food Safety. Staff shall be responsible for daily and weekly cleaning assignments as determined by the Dietary Manager and/or his/her designees; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's choice of code status (the level of medical interventions a resident wishes to have if their heart or breathing stops) was clearly and consistently documented throughout the resident's medical record for three residents (Resident #3, Resident #45 and Resident #105). The facility census was 58. Record review of the facility's policy titled, Advance Directives, dated [DATE], showed the following: -Prior to or upon admission of a resident to the facility, the Social Services Director (SSD) or designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep residents who resided in the special care unit (SCU) free from possible harm by not securing hazardous chemicals and other hazardous items and by allowing resident access to a coffee pot with an external hot water spout. Thirteen residents resided on the SCU and the facility census was 58. 1. Record review showed the facility did not provide a policy related to securing hazardous chemicals. Record review of the Safety Data Sheet (SDS - a document that lists information relating to occupational safety and health for the use of various substances and products) for Provon Perineal Wash, dated 7/26/94, showed the following: -May cause eye irritation or gastric upset; -Keep out of reach of children. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain written consent for side rail use, failed to complete a documented side rail assessment, failed to monitor and measure bed rails for risk of entrapment , failed to obtain physician orders for use of side rails, and failed to complete a risk versus benefits side rail assessment for four residents (Resident #15, #27, #38 and #40). The facility census was 58. Record review of the facility's policy titled Proper Use of Side Rails, reviewed 01/2017, showed the following: -Side rails are only permissible if they are used to treat a resident's medical symptoms or reason for using side rails; -An assessment will be made to determine the resident's symptoms or reason for using side rails; -The use of side rails as an assistive device will be addressed in the resident care plan; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food items were protected from possible contamination when the Special Care Unit (SCU) that held snacks and drinks for the residents was kept clean. The facility's census was 58. 1. Observation on 5/4/22, at 12:19 P.M., of the refrigerator in the SCU that held snacks and drinks for the residents showed the following: -Red and brown dried on particles on the middle shelf in the door, the right and left middle shelf, and bottom shelf, inside the drawer on the left inside and bottom pan under the bottom drawers. Observation on 5/5/22, at 7:25 A.M., of the refrigerator in the SCU that held snacks and drinks for the residents showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to administer the pneumococcal (pneumonia) vaccine to two residents (Resident #27 and #40), and failed to offer the pneumococcal vaccine to one resident (Resident #35). The facility census was 58. Record review of the facility policy titled, Infection Prevention and Control Manual, Resident Immunizations and Vaccinations-Pneumonia Vaccine Program, showed the following: -It is the policy of this facility that residents will be offered immunizations against pneumococcal disease; -Pneumococcal disease is a serious illness that can cause sickness and even death; -There are two pneumococcal vaccines available for use in the United States, 13 valent pneumoni conjugate vaccine (PCV13) and 23-valent pneumococcal polysaccharide vaccine (PPSV23); [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff completed criminal background checks (CBCs) and 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 two employees (Dietary Aide (DA) F and Licensed Practical Nurse (LPN) G). The facility census was 58. Record review of the facility's Abuse Policy, revised November 2018, showed the following: -The facility will not knowingly employ individuals who have been found guilty of abusing, neglecting or mistreating residents or misappropriating their properties; [...]

Inspectors wroteBased on record review and interview, the facility failed to provide a Preadmission Screening and Resident Review (PASRR - a federally mandated preliminary assessment to determine whether a resident may have a mental illness (MI) or an intellectual disorder (ID), to determine the level of care needed) for one sampled resident (Resident #8) out of a sample of 23 residents. The facility census was 58. Record review showed the facility did not provide a policy regarding the completion of PASRRs. 1. Record review of Resident #8's face sheet (admission data) showed the following: -admitted to the facility on [DATE]; -readmitted to the facility on [DATE] from the hospital; -Diagnoses included unspecified convulsions, essential hypertension (high blood pressure), and unspecified mood (affective) disorder. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all residents received care per the facility's policies and procedures and resident's care plan, when staff failed to accurately monitor and document resident bowel movements (BM) resulting in staff not administering laxatives as ordered for one resident (Resident #32). The facility had a census of 55. Record review of the facility's (undated) policy and procedure titled, For Completion (Activities of Daily Living) ADL Flow Sheets, showed the following information: -ADL (activities of daily living - dressing, grooming, bathing, eating, and toileting) Flow Sheets will be completed on each resident to ensure continuity and accuracy of care given to each resident; -The nursing assistant assigned to each hall will be responsible for documenting on the ADL Flow Sheet by the end of each shift; [...]

Inspectors wroteBased on interview and record review, the facility failed to document a discharge summary with information regarding discharge for one resident (Resident #53). The facility census was 58. Record review of the facility's policy titled, Discharge Summary and Plan, reviewed 1/2017, showed the following: -The discharge plan will include resident and family/caregiver education needs and will initiate or maintain collaboration between the nursing facility and other post-acute care providers to support the resident's transition to community living. The discharge plan, instructions, and summary provides a recapitulation (an act or instance of summarizing and restating the main points of something) or summary of the resident's stay. 1. Record review of Resident # 53's face sheet (admission data) showed the following information: -admission date of 1/18/22; -discharge date [DATE]; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to use clean/asepetic technique while performing physician ordered wound care to a diabetic ulcer for one resident (Resident # 41) and failed to apply physician ordered tubigrips (elastic tubular bandages) to one resident's (Resident #17's) legs in a facility with a census of 58. Record review of the facility protocol titled, Treatment Options, revised 4/2018, showed the following: -Chronic wound should be treated using clean (aseptic) treatment technique. 1. Record review of Resident #41's face sheet showed: -admission date of 3/15/22; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to use clean/aseptic (free from contamination) technique to help prevent possible infection while performing physician ordered wound care to a pressure ulcer for one resident (Resident #43) in a facility with a census of 58. Record review of the facility protocol titled, Treatment Options, revised 4/2018, showed the following: -Chronic wound should be treated using clean (aseptic) treatment technique. 1. Record review of Resident #43's face sheet showed: -admitted to the facility on [DATE]; -Resident on hospice services; -Diagnoses included muscle weakness, schizophrenia (mental disorder in which people interpret reality abnormally), and adult failure to thrive. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to consistently provide restorative services, as recommended by therapy, for two residents (Resident #40 and #45). The facility census was 58. Record review of the facility's (undated) policy titled Restorative Nursing Policy and Procedure showed the following: -It is the policy of this facility to provide restorative nursing which promotes the resident's ability to adapt and adjust to living as independently and safely as possible. Restorative nursing focuses on achieving and/or maintaining optimal physical, mental, and psychological function of the resident. The restorative nurse, restorative nurse aide (RNA), along with the interdisciplinary team (IDT), will determine what programs will be initiated for the residents; [...]

Inspectors wroteBased on interview and record, the facility failed to ensure all residents received proper treatment and services for their psychosocial well-being when staff did not update one resident's (Resident #1) care plan and implement new interventions and monitoring after the resident made suicidal comments and had suicidal ideations. The facility census was 58. Record review of the facility's policy titled Behavioral Assessment, Intervention and Monitoring, reviewed 1/2017, showed the following: -As part of the initial assessment, staff will identify individuals with a history of impaired cognition, altered behavior, or mental illness; -As part of the comprehensive assessment, staff will evaluate, based on input from the resident, and representative, review of medical record and general observations the resident's pattern of cognition, mood and behavior; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a medication regimen free from unnecessary medications when the facility failed to implement gradual dose reductions (GDR-a step wise 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) for one resident (Resident #4). The facility census was 58. Record review of the facility's policy titled Consultant Pharmacist Services Provider Requirements, dated 6/1/18, showed the following: -Specific activities that the consultant pharmacist performs includes, but is not limited to: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all residents were free form significant medication errors when staff failed to monitor resident bowel movements (BM) resulting in staff not administering laxatives as ordered for two residents (Resident #22) and (Resident #32). The facility had a census of 58. Record review of the facility's (undated) policy and procedure titled, For Completion ADL Flow Sheets, showed the following information: -ADL (activities of daily living - dressing, grooming, bathing, eating, and toileting) Flow Sheets will be completed on each resident to ensure continuity and accuracy of care given to each resident; -The nursing assistant assigned to each hall will be responsible for documenting on the ADL Flow Sheet by the end of each shift; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide special equipment for one residents (Residents #5) who the facility identified as needing special equipment to assist with eating. The facility census was 58. Record review showed the facility did not provide a policy related to adaptive equipment. 1. Record review of Resident #5's face sheet (a document that gives a patient's information at a quick glance) showed the following: -admission date of 7/6/20; -Diagnoses included legal blindness, anxiety, and depression. Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 4/14/22, showed the following: -Severe cognitive impairment; -Severely impaired vision with no corrective lenses; -Required no assistance from staff for eating. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure 100% of the staff had been fully vaccinated for COVID-19 (a highly contagious virus that causes serious illness or death) or granted a qualifying exemption, when one contracted staff member (Employee R) did not have the required documentation for a medical exemption. The facility failed to fully implement their Staff Vaccination Policy for COVID-19 by failing to ensure all unvaccinated staff followed facility policy and took necessary precautions to help mitigate the spread of COVID-19 by properly wearing N95 (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) or KN95 (a mask similar to the N95, but it has ear loops and is made to meet Chinese standards for medical masks) mask. The facility census was 58. 1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to respond promptly to the toileting and bathing needs for five residents (Residents #7, #15, #45, #46 and #50) out of a selected sample of 24 residents. The facility census was 53. Record review of the facility's policy titled Answering the Call Light, dated October 2010, showed the following: -Answer the resident's call lights as soon as possible; -Listen to the resident's request; -Do what the resident asks of you, if permitted; -If you have promised the resident you will return, do so promptly; -If assistance is needed, turn on the call light to summon help. 1. Record review of Resident #7's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission dated 7/12/18; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain one resident's (Resident #7) dignity by failing to properly cover a urinary catheter (a sterile tube inserted into the bladder to drain urine) bag. A sample of 24 residents was selected for review. The facility census was 53. Record review for the facility's policy titled Catheter Care, dated 10/1/18, did not show reference or guidance to staff regarding covering catheter bags to provide dignity for the resident. 1. Record review of Resident #7's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission dated 7/12/18; [...]

Inspectors wroteBased on record review and interview, the facility failed to provide the facility's bed-hold policy to two sampled residents (Resident #45 and #47) prior to being transferred/discharged to the hospital. The facility census was 53. Record review of the facility's policy titled Bed Hold Policy and Agreement Form, revision dated February 2014, showed the following: -The bed hold agreement is to be obtained for each occurrence of hospital or therapeutic home leave; -When hospital or therapeutic home leave is reported on the midnight census, the business office will notify the resident/responsible party to sign the bed hold agreement; -The business office will address weekend or holiday transfers to the hospital or therapeutic home leave on the next business day. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff revised one resident's (Resident #6) comprehensive care plan to include the development of pressure ulcers, out of a sample of 24 residents. The facility census was 53. Record review of the facility's policy titled Care Plans, Comprehensive Person-Centered, dated December 2016, showed the residents' care plans will include the following: -Services that are provided to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; -Identified problem areas and treatment goals; -Interventions to aid in preventing or reducing decline in the resident's functional status; -Revision to the care plan when the resident's condition changes. 1. Record review of Resident #6's face sheet (a document that gives a resident's information at a quick glance) showed the following: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to follow physician's order for laboratory tests for two residents (Resident #7 and #11) and for supplement oxygen for one resident (Resident #7) out of a sample of 24 residents. The facility census was 53. Record review of the facility's policy titled Laboratory and Diagnostic Testing, dated September 2012, showed the following: -The physician will identify and order diagnostic and lab testing based on the resident's needs; -The staff will process test requisitions and arrange for tests to be completed. Record review of the facility's undated policy titled Oxygen Therapy, showed the following: -A physician order will be obtained and followed for oxygen use. 1. Record review of Resident #7's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission dated 7/12/18; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure medication regimens were free from unnecessary medication when the facility failed to provide rationale to continue an as needed (PRN) psychotropic medication (drugs that alter chemical levels in the brain which impact mood and behavior, used to treat mental illness) past 14 days for one resident (Resident #8) in a selected sample of 24. The facility census was 53. Record review of the facility's policy titled Administering Medications, dated December 2012, showed the following: -If a resident uses PRN medications frequently the physician, interdisciplinary team, and the pharmacist shall reevaluate to determine if there is a clinical reason for the PRN use of the medication ordered. 1. Record review of Resident #8's face sheet (a document that gives a resident's information at a quick glance) showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to use appropriate infection control procedures to prevent or reduce the risk of spreading bacteria or other infectious causing contaminants when staff failed to use appropriate hand hygiene while performing incontinent care for one resident (Resident #7) with a catheter and failed to perform appropriate wound care for one resident (Resident #6) in a selected sample of 24 residents. The facility census was 53. According to the Center for Disease Control's (CDC) Guideline for Hand Hygiene in Healthcare Settings, 2002, volume 51 showed the following: -The hands are the most common mode of transmitting pathogens (microorganisms); [...]