Ash Grove Healthcare Facility

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care per standards of practice when staff failed to complete weekly skin assessments, document accurate wound assessments, obtain orders timely, follow physician orders, and provide treatment as ordered for one resident (Resident #1) who admitted with multiple identified wounds. The facility census was 78. Review showed the facility did not provide a policy regarding wound care. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care per standards of practice when staff failed to complete weekly skin assessments, document accurate wound assessments, obtain orders timely, follow physician orders, and provide treatment as ordered for one resident (Resident #1) and failed to provide treatments as ordered for one resident (Resident #2) with pressure ulcers (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device). The facility census was 78. Review showed the facility did not provide a policy regarding wound care. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all residents received care per the residents' care plans and standards of practice when staff failed to obtain blood sugar parameters for administration of as needed insulin for one resident (Resident #23) and when staff failed to document placement of a physician ordered compression glove or document notification of refusals for one resident (Resident #62). The facility census was 75. Review of the facility policy titled, Physician Orders, last revised November 2024, showed, the following: -If an order is received that is unclear, incomplete, or illegible, clarify the order with the attending physician and document clarification of the order in the medical record; -If the licensed/certified personnel question the appropriateness of an order, the following steps will be taken: [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain a full accounting and record system of resident trust funds when the facility failed to provide a written statement of each resident's trust fund balance and activity to the the resident and/or his/her responsible party quarterly for three residents (Resident #1, Resident #2 and Resident #3). The facility census was 74. Review of the facility policy titled, Pre-Admissions, dated 2024, showed the following: -The business office will manage the resident trust account (RTA); -A quarterly RTA statement will be provided to the resident or responsible party. 1. Review of Resident #'1's face sheet showed the following: -admission date of 08/15/17; -Diagnoses included Alzheimer's disease (gradual decline in mental and physical functions); -Resident had a family member listed as guarantor. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure all residents were treated with respect and dignity when one staff (Certified Nurse Aide (CNA) A) proceeded to give one resident (Resident #1) a shower when the resident resisted and called out and the CNA did not attempt alternate interventions to calm the resident. The facility census is 74. Review of the facility's policy on Resident Rights, updated 10/01/21, showed the following: -Residents have the right to be treated with dignity and respect; -Residents can make their own schedule and participate in activities of their choice; -Residents have the right to reasonable accommodation of needs and preferences. 1. Review of Resident #'1's face sheet showed the following: -admission date of 06/06/22; -Diagnoses included chronic Alzheimer's disease (loss of memory) with late onset. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide care per standards of practice when staff failed to complete timely follow-up, assessment, documentation, and monitoring of a bruise discovered on one resident (Resident #2) who took medication to prevent blood clots. The facility census is 74. Review showed the facility did not provide a policy regarding monitoring and documentation of bruises. Review of Drugs.com guidance on Plavix (a medication used to prevent platelets in the blood from sticking together to form an unwanted blood clot that could block an artery), dated 04/22/24, showed the following: -Plavix keeps blood from clotting to prevent unwanted blood clots that can occur with certain heart or blood vessel conditions; -Because of this drug action, Plavix can make it easier for a person to bleed, even from a minor injury;. [...]

Inspectors wroteBased on record review and interview, the facility failed to protect one resident's (Resident #1) right to be free from verbal/emotional abuse by staff when one staff (Certified Nurse Aide (CNA) A) yelled and cursed at the resident. The facility census was 80. The Administrator and Director of Nursing (DON) were notified on the evening of 03/02/24 of the Past Non-Compliance which occurred earlier on 03/02/24. On 03/02/24, The CNA left for the night and the staff monitored the residents. On 03/03/24, in-services of all staff was started. Staff began the full investigation on 03/04/24 and completed resident interviews on 03/05/24. The facility implemented monitoring including weekly interviews with residents. The noncompliance was corrected on 03/05/24. Review of the facility policy titled, Abuse Appendices, SS0S-09, revised 05/2021, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to report allegations of abuse involving one resident (Resident #1) and one staff (Certified Nurses Assistant (CNA) A) to the State Survey Agency (Department of Health and Senior Services- DHSS) within two hours of receiving the allegation. The facility census was 78. Review of the facility's policy titled, Patient Abuse/Neglect, Elder Abuse, and Persons with Disability Abuse, ADM03-03, revised August 2021, showed the following: -Staff are to report or assist the person with direct knowledge of concerns to report immediately, within two hours of the allegation for mental, physical, verbal, or sexual abuse, or if there has been bodily injury related to abuse; [...]

Inspectors wroteBased on observation, interview, facility policy review, and review of the dishwasher sanitation log, the facility failed to label, date, and cover food stored in refrigeration storage. The facility also failed to discard food in refrigeration storage with expired use by dates and ensure the kitchen's dish machine dispensed sufficient chlorine to sanitize items washed in the machine. This had the potential to affect 76 residents who consumed food prepared in the facility's kitchen.

Inspectors wroteBased on interview, review of facility managed resident fund accounts, and review of the facility's admission Agreement, the facility failed to provide four of four residents (Resident (R) 3, R4, R22 and R42), who had personal funds deposited in the facility, access to petty cash on an ongoing basis. Residents' funds were unavailable to them on weekdays after 4:30 PM and on weekends.

Inspectors wroteBased on observation, interview, test tray observation, record review, review of Resident Council meeting minutes, and facility policy review, the facility failed to serve food that was palatable and hot to ten of ten residents (Resident (R) 3, R127, R4, R17, R22, R23, R42, R48, R59, and R77) reviewed for food palatability. This failure had the potential to affect all 76 residents who consumed food prepared from the facility's kitchen.

Inspectors wroteBased on observation and interview, including facility policy, the facility failed to transport linens in accordance with accepted national standards to prevent the spread of infection. This failure placed all 76 residents at risk of the spread of infectious agents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for three in a total sample of 24 residents (Residents (R62, R2, and R73) whose assessments were reviewed. The facility failed to accurately assess bowel and bladder continence for R62, a prognosis of six or less months for R2, and discharge home for R73. These failures placed the residents at risk of having unmet care needs and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect food from possible contamination when staff failed to ensure the required air gap for two facility ice machines had a two inch gap between the drain in the floor and the tubing from the ice machine that would prevent the backflow of wastewater. This facility practice could lead to contamination of ice and possible food-borne illness, potentially affecting all residents at the facility. The facility had a census of 75. According to the Missouri Food Code, adopted by the Missouri Department of Health and Senior Services (DHSS) June 3, 2013, in order to prevent backflow, a direct connection may not exist between the sewage system and a drain originating from equipment in which food is placed. A backflow prevention device or an air gap must be in place to prevent wastewater back-siphonage. 1. [...]