Avalon View Health and Wellness

Inspectors wroteBased on interviews and record review, the facility failed to ensure the registered nurse working as the charge nurse had a current nursing license. The facility census was 129. On [DATE], the Administrator was notified of the past noncompliance which occurred on [DATE]. On [DATE] facility administration was notified of the incident, an investigation immediately began, and corrective actions were implemented to include; complete audit of all employee files to ensure all staff licenses are current and complete audit of all resident's medical records. All residents were interviewed, and no concerns were noted. The Administrator now reviews all potential new staff hires to ensure all required licenses are current. The noncompliance was corrected on [DATE]. The facility did not provide a policy and procedure regarding licenses verification. [...]

Inspectors wroteBased on interview and record review the facility failed to allow one resident (Resident #1) to exercise his/her rights when funds were transferred from Resident #1's personal checking account to the Business Office Manager's (BOM) personal [NAME] account ( a mobile banking application used to transfer funds from one account to another) without Resident #1's permission. The facility census was 117. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow facility policy and physician orders to implement contact precautions and infection control measures to prevent the spread of scabies for three of three sampled residents, on the special care unit, (Resident #1, #2, and #3). All residents of the special care unit had to be prophylactically treated with 18mg Ivermectin by mouth, and Permethrin topically and showered. The facility census was 118. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff invoked (activated by verifying incapacity of the resident to make decisions) Durable [NAME] of Attorney (DPOA) prior to allowing the designated agent to make medical decisions for the resident. The facility also failed to ensure two residents had designated individuals to make medical decisions when the resident was declared incapacitated by two physicians. This affected seven of eleven sampled residents (Residents #33, #48, #53, #63, #73, and #95). The facility census was 111. Review of the facility's Residents' Rights Regarding Treatment and Advanced Directives Policy, dated 2021, showed:-It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advanced directive. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the environment for one (Resident #1) of five sampled residents remained free of accident hazards and additionally failed to follow their own transportation policy when the resident was injured during transportation in facility vehicle as a result of not being properly restrained and supervised by the facility designated driver. The facility census was 111. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect one resident's (Resident #1) right to be free from physical abuse when Resident #2 hit Resident #1 in the back. Resident #1 was noted to have redness to his/her back. The facility census was 108. On 4/2/25 the Administrator was notified of the past noncompliance which began on 3/24/25. Upon discovery, the facility administration immediately conducted an investigation and corrective actions were implemented. The noncompliance was corrected on 3/24/25. Review of the facility's Abuse, Neglect and Exploitation policy, dated 8/22/2022, showed: -It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property; [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure housekeeping and maintenance services were provided to maintain a sanitary, orderly and comfortable interior throughout the facility. Additionally, the facility failed to ensure furnishings were in good repair. The facility census was 104. Review of the facility provided policy Routine Cleaning and Disinfection dated 9/1/21 showed: -It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment; -Cleaning refers to the removal of visible soil from objects and surfaces; -Horizontal surfaces with infrequent hand contact (window sills and hard surface flooring) in routine areas should be cleaned on a regular basis; when soiling or spills occur; when a resident is discharged ; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance to dependent residents with grooming, and showers at least twice a week for nine of 21 sampled residents (Resident #12, #13, #14 #49, #67, #74, #80, #87, and #91). The facility failed to provide shaving assistance and nail care for one resident (Resident #14). The facility failed to provide incontinent care for two residents (Resident #13 and #80). The facility census was 104 Review of facility policy, Activities of Daily Living, dated 9/1/21, showed: -The facility will ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable including ability to bathe, dress, groom, and toilet. -The facility shall provide a maintenance and restorative program to assist the resident in maintaining the highest practicable outcome based on the comprehensive assessment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing activities program to support the needs of three of 21 sampled residents (Resident #153, #93, and #52). The facility census was 104. Review of the facility provided policy, Activities, dated 9/1/21 showed: -It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences of each resident. Facility sponsored group and individual activities and independent activities will be designed to meet the interests of and support the physical,mental and psychological well being of each resident. -Activities refer to any endeavor, other than routine ADLs(Activities of Daily Living: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to employ a qualified activity professional to oversee the activity program for the facility. The designated employee was employed as the full time activity director for one year, however, had not completed an approved activity professional training program. The facility census was 104. Review of the facility's Activity Director Qualifications, dated 2023, showed: -Activity Director, at a minimum, shall meet the following qualifications: -Licensed or registered by the state in which practicing; -One or more of the following: -Eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body on or after October 1, 1990; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the environment for three of 21 sampled residents (Resident #3, #67, and #89) was free from accident hazards when observations of the memory care unit showed residents had access to the unlocked clean utility room that contained three open electrical boxes, two tanks of oxygen, and cleaning supplies, and the unlocked biohazard room that contained sharps, as well as hazardous chemicals, and the unlocked area behind the nurses desk that contained a jug of drug destroyer and a bottle of multipurpose cleaner. The facility census was 104. Review of the facility's Accidents and Supervision Policy, dated, 9/1/2021, showed in part: -The resident's environment will remain free of accident hazards as is possible; -Each resident will receive adequate supervision to prevent accidents; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had water at bedside that was easily accessible for four of 23 residents sampled (#90 #49, #87, and #12). The facility census was 104. Review of the facility's undated policy for hydration showed, in part: -The facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health. - Nursing staff shall assess hydration status upon admission and throughout the resident's stay in accordance with assessment protocols; the dietary manager or designee shall obtain the resident's beverage preferences upon admission, significant change in condition, and periodically throughout his or her stay; [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide trauma informed care to one sampled resident (Resident #49) with a diagnosis of Post-Traumatic Stress Disorder (PTSD, a mental health condition that is triggered by a traumatic event). The facility failed to mitigate triggers of loud noises that caused re-traumatization for one resident (Resident #49) who was residing on a hall with several residents who scream and yell out. The failed to identify and mitigate triggers for one resident (Resident #87) when the resident had identified several traumatic events. The facility also failed to identify and communicate interventions to staff for both residents to assist in promoting a sense of safety for both residents (Resident #49 and #87). The facility census was 104. Review of facility policy, Trauma Informed Care, dated 9/1/22, showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient nursing staff to meet basic care needs for seven residents (Residents #13, #67, #80, #12, #49, #87, and #74) including assistance to reposition and incontinent care for two residents (Resident #13 and #80), failed to provide basic hygiene for one resident (Resident #67), and failed to provide assistance with bathing for three residents (Residents #12, #49 and #87) of 21 sampled residents. Additionally the facility failed to answer call lights timely for nine of 20 Resident Council attendees. The facility census was 104. Review of the facility provided policy Activities of Daily Living (ADLs: tasks completed in a day to care for oneself) dated 9/1/21 showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store and label drugs and biologicals in accordance with currently accepted professional principles for five (Resident #12,#15, #69, #77 and #154 ) out of 23 sampled residents when the facility failed to store medications in a locked storage area for Resident #12 and Resident #154 and failed to ensure medications were inaccessible to unauthorized staff and residents when the medication cart was left unlocked and unattended. Additionally, the facility failed to ensure staff were able to read the pharmacy label for Resident #69, failed to destroy expired medications for Resident #69 and Resident #77, and failed to destroy expired house stock medications. The facility census was 104. Review of the facility's Medication Storage Policy, revised, 9/1/21, showed in part: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to adequately staff the kitchen with enough dietary staff to ensure meals were served to residents in a timely manner. This has the potential to affect all residents of the facility. The facility census was 104. 1. Review of facility's meal serving policy, dated 12/2/22, showed: -Check on the resident's at regular intervals; -Offer additional fluids and water with the meal when there are no fluid restrictions; Facility did not provide a policy regarding dietary staffing. Review of the facility's planned meal time schedule dated 9/15-9/28/24, showed: -Breakfast 7:30 A.M. -Lunch 11:30 A.M. -Dinner 5:00 P.M. Observations on 9/16/24 showed the following: -11:47 A.M., 19 residents assembled in the dining room for the lunch meal; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the food served to the residents was palatable, attractive, and at a safe and appetizing temperature when staff did not temperature check cooked foods and recipes were not followed for five (#27, #49, #90, #91, and #96) of 21 sampled residents. In addition, 15 of 20 residents from the resident council group interview said the food was cold and recipes were not followed. The facility census was 104. 1. Review of the facility policy, on Palatability and Nutritive Value, dated 6/27/23, showed: - Hot foods will be held at temperature 135 degrees or above and cold foods will be held at 41 degrees or below prior to serving to maintain food safety; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, and serve food in accordance with professional standards of food service safety when staff failed to manually clean and sanitize kitchen equipment, failed to maintain a clean and sanitary kitchen, failed to wash hands, failed to date and label foods, and failed to wear hair and beard coverings. This had the potential to affect all residents in the facility. The facility census was 104. 1. Review of the facility's policy on three compartment sinks, undated, showed: - Dishes and cookware will be cleaned and sanitized after each meal; - Check sanitation sink frequently using a test strip to ensure the level of sanitizing solution is appropriate; - Sink One Wash: Prepare the clean sink by measuring the appropriate amount of water into the sink and marking the sink with a water line. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain all areas of the facility in a safe, functional, sanitary and comfortable environment for visitors, staff and residents. The facility census was 104. Review of the facility provided policy Routine Cleaning and Disinfection dated 9/1/21 showed: -It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment. -Cleaning refers to the removal of visible soil from objects and surfaces. -Horizontal surfaces with infrequent hand contact (window sills and hard surface flooring) in routine areas should be cleaned on a regular basis; when soiling or spills occur; when a resident is discharged . -Cleaning of walls, blinds and window curtains will be conducted when visibly soiled. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat residents with dignity and respect, when staff failed to cover up a resident (Resident #71) who was walking down the hallway in a white pull-up brief, without pants, and failed to assist a resident into his/her personal clothes when requested by the resident (Resident # 74). The facility also failed to provide a resident with clean bed pads and sheets so he/she could return to bed after an incontinent episode (Resident #49). This affected two of 21 sampled residents. The facility census was 104. The facility did not provide a policy on resident dignity. Review of nursing home Resident's Rights, showed: -Residents had a right to be treated with consideration, respect, dignity, and recognizing each resident's individuality. -Equal access to quality of care; -Quality of life is maintained or improved. 1. [...]

Inspectors wroteBased on interviews, the facility staff failed to ensure residents had access to their personal funds after business hours and on the weekends. This impacted three of 21 sampled residents (Resident #83, #28, and #5). The facility census was 104. The facility did not provide a policy regarding access to resident funds. 1. Review of Resident #83's Significant change minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 7/26/24, showed: -He/She had moderately impaired cognition; -He/She had clear speech, was able to make self-understood and understand others; -Diagnoses included depression, cancer of the colon, high blood pressure, and diabetes (too much sugar in the blood). During an interview on 9/16/24 at 12:20 P.M., the resident said: -He/She does not always have access to his/her money; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the code status matched in all places of the clinical record for one resident (Resident #35) out of 23 sampled residents. The facility census was 104. The facility's Advance Directive policy was not provided. 1. Review of Resident #35's admission Minimum Data Set (MDS) assessment, a federally mandated assessment instrument completed by facility staff, dated 7/17/24 showed: Diagnoses included: mild cognitive impairment; Diabetes; Kidney Failure; High Blood Pressure; Gastroesophoageal reflux disease (GERD); and Obstructive uropathy (urinary blockage) Review of resident's physician's orders, dated 7/16/2024, showed: -Full code (Provide life saving measures) status. Review of the resident's Outside the Hospital Do Not Resuscitate Order form (OHDNR) signed on 8/22/24 showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure confidentiality of records was maintained for two of 21 sampled residents (Resident #80 and #153) when durable power of attorney document (DPOA) paperwork for Resident #80 was given to an unauthorized person by facility staff and when empty medication packaging was observed outside the facility on the ground with Resident #153's personal information on the label. The facility census was 104. Review of the facility's Health Insurance Portability and Accountability Act (HIPAA) Policy dated, 9/1/21, showed in part: -It is the facility's policy to implement reasonable an appropriate measures to protect and maintain the confidentiality, integrity and availability of the resident's identifiable information or records; -Security measures will be implemented to manage risks and vulnerabilities. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comprehensive care plan was developed and implemented for two sampled residents (Resident #153 and #52 ) out of 21 sampled residents. The facility census was 104. Review of the facility provided policy Comprehensive Care Plans, dated 9/1/21 showed: -It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident; to meet the resident's medical, nursing, and mental and psychological needs identified in the resident's assessment. -The comprehensive care plan will describe, at a minimum: services to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial wellbeing; Any specialized services; and the resident's goals. 1. [...]

Inspectors wroteBased observation, interview, and record review, the facility staff failed to follow physician's orders and apply a resident's cervical collar (neck brace) as ordered daily for one resident (Resident #52) who was dependent upon staff for mobility and assistance with care. This affected one of twenty-one sampled residents. The facility census was 104. Review of facility policy, provision of physician ordered services, dated 2022, included professional standards of quality means that care and services are provided according to accepted standards of clinical practice. 1. Review of Resident #52's admission minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 7/26/24, showed: -His/Her cognitive status was not testable; -He/She had no speech; -He/She rarely or never understand others; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to prevent flies and roaches. The facility census was 114. Review of the facility provided Pest Control Policy dated 9/1/22 showed: -It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents -The facility will utilize a variety of methods in controlling certain seasonal pests, i.e. flies. These will involve indoor and outdoor methods that are deemed appropriate by the pest service and state and federal regulations. Observations beginning on 09/16/24 at 12:58 P.M. on [NAME] Hall showed: -Large cobwebs with dead bugs at the corner of the exit door. -Multiple flies in room B1. [...]

Inspectors wrotePlease refer to Event ID 45RI12 for additional details. Based on observations, interviews and record review, the facility failed to ensure staff provided care in a manner to preserve and enhance residents' dignity when staff did not ensure call lights were within reach for three residents(Residents #100, #9, and #40), when staff did not respond to call lights timely for one resident (Resident #19), and when staff moved two residents' personal belongings without them being present (Resident #7 and #58). This affected seven of 28 sampled residents. The facility census was 82. Review of the facility's Resident Rights policy, revised 9/1/22, showed: -The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. -The right to receive services and/or items included in the plan of care; [...]

Inspectors wroteRefer to Event 45RI12 for SOD. This deficiency is uncorrected. For previous examples, please see the Statement of Deficiencies dated 12/14/23. Based on observation and interviews, the facility failed to maintain a clean and comfortable homelike environment when staff failed to keep all areas of resident rooms and hallways clean, did not keep trash picked up off the floor, keep floors free of dirt and grime, and wipe down over-bed tables. The facility census was 82. Review of facility policy, Routine Cleaning and Disinfection, dated 9/1/21, showed: -Ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to extent possible; [...]

Inspectors wroteRefer to SOD at 45RI12 This deficiency is uncorrected. For previous examples, see the Statement of Deficiencies dated 12/14/23. Based on observation, interview, and record review, facility staff failed to provide dressing, shaving, grooming, and bathing assistance for four of 26 sampled residents (Residents #3, 100, #19, and #33). The facility census was 82. Review of facility policy, Activities of Daily Living (ADLs), dated 9/1/21, showed: -The facility will ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable; -The facility shall provide a maintenance and restorative program to assist the resident in achieving and maintaining the highest practicable outcome based on the comprehensive assessment; -A resident who is unable to carry out ADLs will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene; [...]

Inspectors wroteBased on observation, record review, and interview the facility failed to prepare and serve food in accordance with professional standards for food service safety when staff failed to keep a clean kitchen, failed to store food off the floor, failed to label food when it was opened, failed to temperature check foods at food service time, and failed to ensure staff washed their hands when contaminated. The facility census was 82. Review of facility policy, Food Safety Requirements, undated, showed: -Food will be stored, prepared, distributed, and served in accordance with professioanl standards for food service safety. -Food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with the delivery of the food to the resident. Elements of the process include the following: [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure staff provided care in a manner to preserve and enhance residents' dignity when staff did not ensure call lights were within reach for three residents(Residents #100, #9, and #40), when staff did not respond to call lights timely for one resident (Resident #19), and when staff moved two residents' personal belongings without them being present (Resident #7 and #58). This affected seven of 28 sampled residents. The facility census was 82. Review of the facility's Resident Rights policy, revised 9/1/22, showed: -The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. -The right to receive services and/or items included in the plan of care; -The resident has a right to be treated with respect and dignity; [...]

Inspectors wroteBased on observation and interviews, the facility failed to maintain a clean and comfortable homelike environment when staff failed to keep all areas of resident rooms clean, did not keep trash picked up off the floor, keep floors free of dirt and grime, remove used meal service dishes from rooms, empty trash in resident rooms, change dirty linens, and wipe down over bed tables, and properly clean soiled and stained furniture that was readily accessible to the residents of [NAME] hall and Maple hall. This affected eight (Resident #62, #18, #69, #35, #3, #40, #55, #31) of 20 sampled residents. The facility census was 82. Review of the facility Residential Environmental Quality policy, dated 9/28/22 showed: [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure that the criminal background check (CBC) of three out of six sampled nursing staff employees was completed, when the facility did not provide in the employee HR (Human Resource) file that the facility had completed a criminal back ground check through the Missouri State Highway Patrol (MSHP) prior to allowing resident contact, nor did they retain any documentation supporting that it had been completed by the facility. The facility census was 82. Review of the Missouri State Statute Chapter 192.2495 dated 8/28/18 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two residents(Resident #8, and #15) who had a diagnosis of bipolar disorder and unspecified psychosis ( both are a serious mental disorder in which people interpret reality abnormally) had a Preadmission Screening and Resident Review (PASARR) completed and reviewed by the facility as part of the resident's admission into the facility. The facility census was 82. The facility did not provide a policy for PASARR. 2. Review of Resident #15's quartley Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 9/26/23., showed: - A brief interview of mental status (BIMS) score of 11, indicating moderate cognitive impairment. [...]

Inspectors wroteBased on observation, record review and interviews, the facility failed to provide care and treatment in accordance with professional standards of practice when licensed nursing staff failed to ensure that physician orders were carried out correctly for Residents #25, #35, and #45. This affected three out of the 18 sampled residents directly for medication administration,The facility census was 82. The facility did not provide a policy on documentation of mediation administration. 1. Review of Resident #45's significant change minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 10/31/23, showed: -Resident was cognitively intact; -Required partial to moderate assistance with showers, toileting hygiene, and tub or shower transfers; -Utilized motorized wheelchair; [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to provide bathing assistance and document showers for three of the 18 sampled dependent residents (Resident #40, #55, and #3). The facility census was 82. The facility did not provide a policy on activities of daily living (ADL's). 1. Review of Resident #40's annual minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 9/26/23 showed: -Moderately impaired cognition; -Required substantial or maximal assistance with shower and bathing self, lower body dressing, sitting to standing mobility, chair to bed transfers; -Used a manual wheelchair for mobility; -Diagnoses included: [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure that four of 20 sampled residents, (Residents #45, #8, #25, and #33) who required staff assistance, were provided with adequate assistance for activities of daily living (ADL's: tasks completed to care for oneself daily such as bathing, dressing, moving from a chair to bed, and personal hygiene). The facility census was 82. The facility did not provide a policy on ADLs. 1. Review of Resident #25's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/17/23 showed: - A Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment; - The resident requires setup assistance for eating and oral hygiene; - The resident is dependent on staff for toileting hygiene, rolling, bathing, and transfers; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess residents for risk of entrapment from bed rails prior to installation for and failed to ensure the bed's dimensions were appropriate for the resident's size and weight, and failed to ensure scheduled maintenance of any bed rail, and failed to use an alternative to side rails, for four of 18 sampled residents (Resident,#40, #35, #5 and #33). The facility census was 82. Review of facility policy, Bed Maintenance and Inspections, dated 2022 showed: -It is the policy of this facility to conduct regular inspections of all bed frames, mattresses, and bed rails, if any, as part of a regular maintenance program to identify and avoid areas of possible entrapment. -The maintenance director, or designee, is responsible for keeping records of bed inspections and maintenance. [...]

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. The facility census was 82. 1. Review of the facility's staffing timesheets, dated 04/01/23 to 5/31/23, showed no RN coverage for the following dates: -04/08/23; -04/09/23; -05/13/23; -05/21/23; -05/29/23; -05/30/23; and -05/31/23. Review of facility's timesheets, dated June 2023, showed RN coverage as the DON for eight hours no clock in or out. During an interview, on 12/14/23 at 04:43 P.M., the Administrator and Director of Nursing (DON) said they do not believe that they have had that many days without an RN, especially now that the DON is working in the building most days. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure staff administered medications with a medication error rate of less than 5%. Facility staff made two medication errors out of 25 opportunities for error which resulted in a medication error rate of 8%, which affected two out of 20 sampled residents, (Resident #13 and #16). The facility census was 82. The facility did not provide a policy for administration of medications. 1. Review of Resident #16's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/3/23 showed: - A Brief Interview for Mental Status (BIMS) score of 2, indicating severe cognitive impairment; - The resident needs setup assistance with eating, oral hygiene, and personal hygiene; [...]

Inspectors wrote2. Review of Resident #20's quarterly MDS, dated [DATE]., showed: - BIMS score of 15 indicating that resident is cognitely intact. - Dependent on staff for medication administration and insulin administration. - Diagnoses includes: Diabetes Mellitus (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces), Diabetic Neuropathy (painful tingling in the hands and feet as a result of diabetes), and history of Tramatic Brain Injury. Review of the resident's care plan, date 4/28/21., showed: - Resident has history of Tramatic Brain Injury. - Resident has Diabetes Mellitus Type 2. - Diabetes medication as ordered, and monitor for side effects. - Check blood sugars before meals and at bedtime. - Notify the physician is above 400 or below 60. [...]

Inspectors wroteBased on observation interviews, and record review, the facility failed to serve meals according to scheduled meal times. This affected two of 18 sampled residents (Residents #33 and #25) . This had to potential to impact all residents residing in the community. The facility census was 82. Review of the facility posted meal times showed: -Breakfast to be served at 7:30 A.M. -Lunch to be served at 11:30 A.M. -Dinner to be served at 5:30 P.M. Review of facility policy, Food Safety Requirements, dated February 2023, showed: -Food and beverages shall be distributed and served to residents in a manner to prevent contamination and maintain food at the proper temperature; -Timely distribution of all meals/snacks. 1. Observation on 12/11/23 at 9:43 A.M. showed breakfast hall trays on Maple hall being served two hours and 13 minutes after posted meal time. Observation on 12/11/23 at 1:15 P.M. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Staff failed to follow acceptable standards of practice for the 2019 Novel Coronavirus Disease COVID-19 (COVID-19,(an infectious disease caused by severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2)), when staff failed to apply and properly wear personal protective equipment (PPE) when entering Covid-19 positive rooms (Residents #35, #48, and #332), failed to sanitize or wash hands (Residents #35, #48, and #332,) , left a resident's door open who was Covid positive (Resident #332), and when the facility failed to provide doffing containers in resident's rooms (Resident #35, #48, and #332,). [...]

Inspectors wroteBased on observation and interview, the facility staff failed to ensure they maintained the building in good repair. The facility census was 82. Observation on 12/11/23 at 4:42 P.M., on 12/12/23 starting at 10:33 A.M., and on 12/13/23 starting at 9:46 A.M., showed: - Duct tape used to repair the chair in the resident's telephone room; - The packaged terminal air conditioner (PTAC) unit in the window missing all the knobs and three of the fins broken/missing in room E10; - A crack in the ceiling around the bathroom light in room E8; - The exhaust vent had two screws lose and it pulled away from the ceiling half an inch in the bathroom in room E2; - The bathroom exhaust vent lined with debris in room B22; - The bathroom exhaust vent lined with debris in room B8; - Two fins broken/missing on the PTAC unit in room D12; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an annual dental exam for one sampled resident (Resident #15) and additionally failed to provide a dental consult for resident #15 who was requesting to be evaluated for replacement dentures for over one year. The facility census was 82 residents. 1. Review of resident #15's quarterly Minimum Data Set (MDS) dated [DATE] showed: -Resident with a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive impairment. -Diagnosis of dementia (a condition characterized by progressive or persistent loss of intellectual functioning). -Oral and Dental Status not completed on MDS. -Resident was independent eating, ambulation, and dressing. Review of resident's Care Plan, initiated 4/19/21 and revised on 10/10/23., showed: -Change in dentition and/or oral hygiene. [...]