Avenir at Mark Twain

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received adequate assistance to prevent accidents when Certified Nurse Aide (CNA) F provided improper transfers to two residents (Residents #3 and #4) resulting in injury. Resident #3 was identified by the facility as requiring a Hoyer lift for transfers. On 05/16/26, CNA F transferred the resident by picking up the resident without a lift, a gait belt, or another employee to assist. The resident's foot got caught, resulting in a fractured right tibia (shin bone) and fibula (calf bone). CNA F was suspended, re-educated on the facility's transfer policies, and returned to work. Resident #4 was identified by the facility as requiring two staff to assist with transfers. On 05/27/26, CNA F performed a transfer by him/herself to assist the resident to the bathroom. CNA F did not use a gait belt. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident's representative after the resident fell, for one out of three residents sampled for falls. (Resident #1). The census was 75. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 11/10/25, showed:-Cognitive intact;-Diagnoses included: diabetes, high blood pressure, end stage renal failure (ESRD, chronic irreversible kidney failure) dependence on renal dialysis (a life-sustaining treatment that filters waste products and excess fluid from the blood when the kidneys are no functioning properly);-Mobility devices: wheelchair and walker;-One fall since admission/entry or reentry;-Partial/moderate assistance (helper does less than half of the effort. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure services meet professional standards of quality by failing to follow physician orders to call the physician when blood sugar levels were out or range and/or obtaining blood sugar checks as ordered. In addition, staff failed to obtain a physician order for when staff should notify the physician of blood glucose (sugar) levels that are out of range for three residents (Residents #6, #1, and #4). The sample was 6. The census was 75. Review of the facility's Nursing Care of the Older Adult with Diabetes's Mellitus (DM, metabolic disease) policy, undated, showed:-Glycemic targets (a personalized blood glucose goal set by a healthcare provider to manage diabetes): [...]

Inspectors wroteBased on interview and record review, the facility failed to thoroughly and accurately assess and document a resident's surgical wound upon admission, then weekly per the facility's policy for one resident (Resident #1). The sample was 6. The census was 75. Review of the facility's Skin Integrity-Pressure and Non-Pressure policy, undated, showed:-Purpose: to establish guidelines for assessing, monitoring and documentation the presence of the skin breakdown, pressure injuries and other non-pressure skin conditions and assuring interventions are implemented;-Guidelines: non-pressure skin conditions (surgical wounds) will be assessed for healing process and signs of complications or infection;-A skin condition assessment will be completed at the time of admission/readmission;-Resident identified will have a weekly skin assessment by a licensed nurse. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received care and treatment in accordance with professional standards of practice when staff failed to administer treatments as ordered for non-pressure wounds, to complete comprehensive skin assessments on a routine basis, and to reassess for efficacy of treatments for skin integrity issues for one resident (Resident #54). The sample was 6. The census was 72. Review of the facility's Skin Assessment policy, revised 1/18/24, showed:-Policy: It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were treated in a dignified manner affecting 5 of 18 sampled residents (Residents #1, #58, #64, #28 and #5). The census was 75. Review of the facility's resident's rights policy, undated, showed:-Employees shall treat all residents with kindness, respect, and dignity;-Residents are entitled to exercise their rights and privileges to the fullest extent possible. Our facility will make every effort to assist each resident in exercising his or her rights to assure that the resident is always treated with respect, kindness, and dignity;-Respect: Treat others as you want to be treated-every person matters. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a homelike environment to all residents in the facility by failing to keep resident rooms at a comfortable temperature and cleanliness (Residents #26, #1, #64), ensuring bed sheets are changed when soiled (Resident #47) and failing to keep resident shower rooms free of obstruction. Concerns were noted with the cleanliness of resident rooms for four out of 18 sampled residents in addition to resident shower rooms on the [NAME] hall. The census was 75.1. Review of Resident #26's medical record, showed diagnoses included bipolar disorder (mood disorder that can cause intense mood swings), depression, seizure disorder, generalized muscle weakness, difficulty walking, unsteadiness on feet, and other abnormalities of gait and mobility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to have a system in place to safeguard resident's personal belongings for two residents (Resident # 68 and Resident #9). The facility also failed to have an admissions policy that did not require residents to waive the facility of liability for loss of personal property. The sample was 18. The census was 75. Review of the facility's current admission packet showed:Personal Property of Resident: The resident is strongly urged to mark all his or her clothing and personal property for easy identification. The resident or authorized representative will be responsible to complete a personal items inventory sheet and update the inventory sheet as needed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received an accurate assessment reflective of the residents' status at the time of assessment by coding side rails as restraints on the Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) for four residents who were determined to use side rails without restriction of freedom of movement (Residents #49, #10, #11, and #35). The sample was 18. The census was 75. Review of the facility's Resident Assessment Instrument (RAI) policy, created 4/14/25, showed facility will adhere to Centers for Medicare and Medicaid Services (CMS) regulations which are considered the definitive source in completion of the RAI process. This includes coding the MDS with accuracy, completion of Care Area Assessments (CAAs) and the development of the comprehensive care plan. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure services provided met professional standards of practice when one resident (Resident #27) did not receive his/her routine anti-anxiety medication as prescribed for over two weeks. The facility also failed to document accurate weights on one resident (Resident #10) and failed to document when two residents (Resident #9 and Resident #68) left the facility for outside appointments and when the residents returned to the facility. The sample was 18. The census was 75. Review of the facility's Medical Provider Orders policy, revised 4/7/23, showed:-Policy: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide respiratory services consistent with professional standards of practice when staff failed to ensure oxygen tubing and nebulizer (a medical device that administers breathing medication in an aerosol form) face masks were changed when contaminated and properly stored for two residents (Resident #1 and Resident #17). The staff failed follow the physician orders and ensure the resident was received the ordered amount of oxygen for three residents (Resident #17, Resident #10 and Resident #55). The sample was 18. The census was 75. Review of the facility's Oxygen and Therapy Policy and Procedure, undated, showed:-Purpose: To ensure residents who require oxygen therapy receive safe, person-centered, and clinically appropriate respiratory care consistent with professional standards of practice;-Policy Statement: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess residents for safety for side rail use, to obtain informed consent for the use of side rails, and to have a policy that provided guidance for staff assessing residents for use of side rails that were not used as a restraint (Residents #35, #11, #48, #10, #49, and #2). The facility identified 14 residents with side rails. The sample was 18. The census was 75. Review of the facility's Use of Restraints policy, reviewed February 2021, showed: - Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body;-The definition of a restraint is based on the functional status of the resident and not the device. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were served food at a palatable, safe, and appetizing temperature during meal service. This affected 10 of 18 sampled residents (Residents #5, #7, #17, #26, #27, #48, #54, #60, #64 and #68). The census was 75. Review of the facility's meal temperature policy, revised 1/2019, showed:-Purpose: To ensure appropriate food temperatures during meal service and to ensure appropriate food holding temperatures. To comply with federal and state regulations governing food meal service;-Policy: Meals temperatures shall be monitored by the Dietary Manager and the Cooks on a daily basis. Hot food shall be cooked or heated to a temperature above 165 degrees Fahrenheit (F) . Cold food shall be chilled to a temperature below 40 degrees F. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that accommodates resident allergies and preferences, and to provide alternative meal options (Residents #26, #5, #49, #48, #60, #27, #35, and #55). The sample was 18. The census was 75.1. Review of the facility's resident council meeting minutes, showed:-On 6/25/25, 13 residents in attendance. Staff are not properly reading the tickets and sending meals to their rooms that their tickets state they do not want. Alternative menus - some meals they do not have in the kitchen, so they do not reach out to ask if they want another alternative meal; -On 7/16/25, 20 residents in attendance. Residents complained the kitchen staff is rude and fail to read the tickets accurately. They also noted that some meals are not available. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure kitchen cooking appliances were in working order, failed to ensure the kitchen and appliances were clean and failed to ensure the dishwasher was in working order. The sample was 18. The census was 75. Review of the facility's kitchen daily cleaning schedule, undated, showed:-The cook is responsible for cleaning the oven, deep fryer, steam table, preparation station table, and microwave;-Dietary Aides are responsible for cleaning stainless steel, walk-in freezer, dish machine area, reach in refrigerator, and walk-in refrigerator. Review of the kitchen maintenance logs, showed no maintenance requests were made from 1/1/25 to 8/20/25 for the broken oven, range oven or walk-in freezer door. 1. Observation on 8/14/25, of the kitchen, showed:-At 10:17 A.M., the walk-in freezer door did not close all the way. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain documentation and provide evidence of an ongoing Quality Assurance and Performance Improvement (QAPI) program that demonstrated systemic identification, reporting, investigation, analysis, and prevention of adverse events, and development, implementation, and evaluation of corrective actions or performance improvement activities. The census was 75. During an interview on 8/14/25 at 10:21 A.M., the Director of Nurses (DON) and Administrator said they began working at the facility approximately two months ago. Quality Assessment and Assurance (QAA) meetings should take place monthly and should be attended by the facility's department heads and Medical Director. The DON and Administrator were asked to provide documentation of the facility's QAPI plan. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable disease and infections. The facility failed to ensure employee two-step tuberculin skin tests were completed in accordance with State guidelines for three out of 10 employees reviewed. [...]

Inspectors wroteBased on interview and record review the facility failed to provide documentation of ongoing educational training provided to active Certified Nursing Aides (CNAs), totaling no less than 12 hours per year, for four of six sampled active CNAs. Insufficient training documentation was provided for four of six sampled CNAs. The sample was 18. The census was 75.1. Review of CNA E's CNA Annual In-Service Training Log, showed:-Inservices completed each month from January 2025 to June 2025, with each inservice totaling one hour;-No record of inservices completed prior to January 2025. 2. Review of CNA Z's CNA Annual In-Service Training Log, showed:-Inservices completed each month from January 2025 to June 2025, with each inservice totaling one hour;-No record of inservices completed prior to January 2025. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents' self-determined preferences and requests were implemented. The facility failed to assist two dependent residents to get out of bed after breakfast, in accordance with their preferences (Resident # 48 and Resident #49). In addition, staff failed to provide one resident a shower when requested (Resident #68). The sample was 18. The census was 75. Review of the facility's Resident Rights policy, undated, showed:-Residents are entitled to exercise their rights and privileges to the fullest extent possible: The facility will make every effort to assist each resident in exercising his/her rights to assure the resident is treated with dignity, kindness, and respect; -Self-determination: Personal freedom means allowing residents to make decisions about themselves. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure third party liability (TPL) forms were completed within 30 days for the final accounting for residents who expired. This affected three out of five sampled residents who expired and had money in their accounts (Residents #77, #78, and #79). The census was 75. Review of the facility's Resident Trust Fund policy, revised [DATE], showed:-Purpose: To establish policy and procedures for the Facility Resident Trust Fund;-Policy: It will be the policy of the management company that the Resident Trust Fund is managed and accounted for in accordance with State and Federal regulations. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete criminal background checks on newly hired employees prior to the employee's start date, and/or failed to ensure newly hired employees were screened to rule out the presence of a Federal Indicator through the Nurse Aide (NA) Registry, for five of 10 employees hired since the last survey. In addition, the facility's policy for screening new hires failed to include completion of checking the NA Registry. The census was 75. Review of the facility's Abuse, Neglect, and Exploitation policy, revised June 2024, showed:-Policy: 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;-Screening:-A. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Activities of Daily Living (ADL) needs were met for three of 18 sampled residents. The facility failed to ensure general hygiene needs were met for two residents (Residents #1 and #64) and feeding assistance was provided to one resident (Resident #28). The sample was 18. The census was 75. Review of the facility's ADL policy, undated, showed:-Purpose: To ensure residents receive assistance with ADLs to maintain or enhance their dignity, independence, and quality of life, while preventing avoidable decline in function;-Procedure: Care plans will reflect each resident's functional status, strengths, limitations, and preferences. Staff will provide individualized assistance with bathing, grooming, dressing, eating, mobility, toileting, and hygiene as needed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident received proper treatment and care to maintain mobility and good foot health (Resident #3). The sample was 18. The census was 75. Review of the facility's Nail and Foot Care policy, undated, showed:-Purpose: To ensure residents receive safe, hygienic, and person-centered nail and foot care that promotes dignity, prevents infection, and maintains independence in accordance with facility standards;-Procedures: On admission and quarterly, nursing staff will assess nail and foot status; Residents' care plan will reflect frequency and level of nail and foot care required;-Restrictions: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure fall interventions were in place for two residents who were identified as high fall risks (Resident #3 and Resident #17). The facility also failed to ensure one resident with a diagnosis of dysphagia (difficulty swallowing) was in an upright position during meals to prevent choking or aspiration (food or liquids that is inhaled into the lungs) (Resident #10). The sample was 18. The census was 75. Review of the facility's Fall Prevention Policy (S.A.F.E.), revised February, 2001, showed;Policy: The S.A.F.E. program promotes Safety, Assessment, Fall prevention and Education of both staff and residents; At the time of admission and re-admission the Fall Risk Data Collection and Fall Risk Questionnaire will be completed; Residents found to be at high risk for falls are place on the S.A.F.E. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide or obtain laboratory services to meet the needs of one resident (Resident #9). The sample was 18. The census was 75. Review of the facility's Test Results policy, undated, showed:- Results of laboratory, radiological, and diagnostic tests shall be reported to the facility.-The medical practitioner shall be notified of the results.-The Director of Nursing (DON), or nurse receiving the test results, shall be responsible for notifying the medical practitioner of such test results. Review of the facility's Medical Provider Orders, revised 4/7/23, showed:-Policy: -This facility shall use uniform guidelines for the ordering and following of medical provider orders;-Documentation of medication and treatment orders: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident received double portions and nectar-thick liquids for aspiration precautions in accordance with physician orders (Resident #47). The sample was 18. The census was 75. Review of Resident #47's medical record, showed:-Diagnoses included pneumonitis (inflammation of the lungs) due to inhalation of food and vomit, dysphagia (swallowing disorder), history of stroke, epilepsy (seizure disorder), and hypertension (high blood pressure);-A physician order, revised 12/13/24, to admit to hospice with admitting diagnoses of aspiration pneumonia;-A physician order, dated 2/26/25, for regular diet, regular texture, nectar-thick liquids. Double portions. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Quality Assessment and Assurance (QAA) committee meetings were held at least quarterly to fulfill the committee's responsibilities to identify and correct quality deficiencies effectively. The census was 75. During an interview on 8/14/25 at 10:21 A.M., the Director of Nurses (DON) and Administrator said they began working at the facility approximately two months ago. QAA meetings should take place monthly. QAA meetings should be attended by the facility's department heads and Medical Director. Review of the facility's QAA sign in sheets for the last 12 months, from August 2024 to August 2025, showed:-Meeting held 9/6/24;-Meeting held in April 2025;-No documentation of other QAA meetings held within the 12-month timeframe. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop policies and procedures ensuring all residents in the facility had been offered the influenza vaccine. The facility failed to ensure documentation of received vaccines were noted in the medical records of three of five sampled residents (Residents #5, #11 and #4). The resident sample was 18. The facility census was 75. Review of the facility's Resident Immunizations and and Vaccinations policy, revised in 2019 showed:-It is facility policy that all residents are offered influenza vaccination annually;-All new admissions will be screened and given the influenza vaccine, unless specifically ordered by the Primary Physician;-A record of vaccination will be placed in the resident's medical record. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop policies and procedures ensuring all residents in the facility had been offered COVID-19 vaccine education and/or had documentation of vaccination against COVID-19 in their facility medical record The facility failed to ensure documentation of received vaccines was noted in the medical records of three of five sampled residents. The resident sample was 18. The facility census was 75. Review of the facility's Resident Immunizations and and Vaccinations policy, revised in 2019 showed:-It is facility policy that all residents are offered influenza vaccination annually;-It is facility policy that all residents are offered pneumococcal vaccination;-No mention of vaccination against or education regarding COVID-19. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the kitchen was free from flies during two of five days of survey. The sample was 18. The census was 75. 1. Review of the facility's pest control logs, showed:-On 6/20/25 the kitchen was treated for pests;-On 7/18/25 the kitchen was treated for pests;-On 8/15/25 the kitchen was treated for pests. 2. Observation on 8/15/25, of the kitchen, showed:-At 11:41 A.M. multiple flies flew around the food preparation station, landing on food and utensils;-At 11:50 A.M., the Dietary Manager stopped food preparations to kill a fly with a bottle of cleaning wipes;-At 12:07 P.M., multiple flies flew around the dish washing station landing on clean and dirty dishes. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate basic life support, including cardiopulmonary resuscitation (CPR, a lifesaving technique that's used in emergencies in which someone's breathing or heartbeat has stopped) for one (Resident #1) of three sampled residents, who was found by staff without a pulse. Staff started CPR on a resident with full code orders but stopped before Emergency Medical Services (EMS) arrived. The Certified Nurse Aides (CNAs) on duty said they did not know how to determine code status. EMS was not notified timely, the resident was discovered without pulse at 5:10 A.M. and EMS was not contacted until 6:14 A.M. The resident expired. Additionally, the facility failed to provide CPR qualified staff for 14, full eight hour shifts between [DATE] through [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all alleged violations involving neglect were reported immediately, but not later than two hours after the allegation is made, to the State Survey Agency for one resident (Resident #1) after the facility was made aware staff started cardiopulmonary resuscitation (CPR) and stopped before Emergency Medical Services (EMS) arrived. The sample was 3. The census was 71. Review of the facility's Abuse, Neglect and Exploitation Policy, revised 6/24, showed: -Policy: 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; -Definitions: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three residents (Residents #3, #1, and #5) received care in accordance with acceptable standards of practice when staff failed to complete progress notes when a resident had a fall (Residents #3 and #5), was sent to the hospital, and returned from the hospital (Resident #3). The facility failed to complete post fall follow up for 72 hours that included, progress notes per shift (Residents #3, #1 and #5), vital signs per shift (Resident #3), and neurological checks (neuro check - pulse rate, respiration rate, and blood pressure measurements; assessment of pupil size and reactivity; and equality of hand grip strength) (Resident #1) in accordance with facility policies. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure professional standards of practice were met, when the facility failed to ensure one out of three resident's labs were obtained per physician orders (Resident #108). The census was 80. Review of the facility's Laboratory Services and Reporting Policy, dated reviewed/revised on 8/18/2023, showed: -Policy: The facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law; -The facility must provide or obtain laboratory services to meet the needs of its residents. Review of Resident #108's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 7/15/24, showed: -Cognitively intact; -Diagnoses included: [...]

Inspectors wroteBased on interview and record review, the facility failed to immediately report an allegation of staff to resident verbal abuse, which was overheard by Resident #1, involving Resident #2 and Certified Nurse Aide (CNA) A to the Department of Health of Senior Services (DHSS) within the required two-hour time frame. The sample was 2. The census was 82. Review of the facility's undated Abuse Prohibition Policy, showed: -Facility operation policy: each resident has the right to be free from abuse, corporal punishment, involuntary seclusion, neglect, misappropriation of resident property or exploitation. Residents must not be subjected to abuse by anyone, including but not limited to staff, other residents, consultants, volunteers, agency staff, family or legal guardians; -Definitions: -Abuse: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to investigate an allegation of verbal abuse between Certified Nurse Aide (CNA) A and Resident #2 which was overheard by Resident #1 from the shared bathroom of Resident #1 and #2. Resident #1 reported the incident to the facility's Social Worker (SW) on 4/4/24. The allegation was not investigated following the resident notification. The sample size was 2. The census was 82. Review of the facility's undated Abuse Prohibition Policy, showed: -Facility operation policy: each resident has the right to be free from abuse, corporal punishment, involuntary seclusion, neglect, misappropriation of resident property or exploitation. Residents must not be subjected to abuse by anyone, including but not limited to staff, other residents, consultants, volunteers, agency staff, family or legal guardians; -Definitions: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident environment remained free from hazards and residents received supervision per the facility's smoking protocol and individual resident smoking assessments when five residents were left unattended in the outside courtyard without staff available to let them back in for approximately 30 minutes during freezing weather conditions, with a temperature of 22 degrees Fahrenheit (F) and wind speeds of nine miles per hour (mph) (Residents #69, #58, #65, #63 and #68). One resident (Resident #69) required supervision at all times for safety. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure general accounting principles were followed by failing to follow up on outstanding checks during monthly resident trust fund reconciliations. The facility identified 20 residents with funds handled by the facility. The census was 69. Review of the facility's Resident Trust Fund (RTF) policy, undated, showed: -Purpose: To establish policy and procedures for the facility RTF; -Policy: It will be the policy of the management company that the RTF is managed and accounted for in accordance with state and federal regulations. Each facility should follow the state guidelines of the payment programs using the greatest level of specificity if requirements vary in state and federal programs; -Procedure included: -The resident fund bank account must be reconciled monthly immediately upon receipt of the bank statement. [...]

Inspectors wroteBased on interview and record review, the facility failed to check for a federal indicator (identifies when an employee who has ever held a Certified Nurse Aide (CNA) certificate and has ever been found to have abused, neglected, or misappropriated resident property) through the state Nurse Aide (NA) registry, for six of 10 employee files reviewed, and failed to ensure checking for a federal indicator was part of the facility's abuse policies for employee screening. The census was 69. Review of the facility's Abuse, Neglect, and Exploitation policy, revised 11/23/23, showed: -Policy: 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 interview and record review, the facility failed to have a system in place to ensure Certified Nurse Aides (CNAs) received the required 12 hours of annual in-service training, for five of five CNAs sampled. The facility identified 13 CNAs employed more than a year. The census was 69. Review of the facility's Facility Assessment Tool, last updated 11/23/23, showed staff training/education is conduced by in-services, 1 on 1 training, and education packets with post-tests. Clinical staff is monitored for 1 on 1 competencies. Mandatory 12 hours for nurse aide training, etc. Review of the facility's in-service binder, showed: -CNA W, date of hire 7/1/98; -CNA V, date of hire 2/6/14; -CNA Y, date of hire 3/2/20; -CNA X, date of hire 11/1/22; -CNA O, date of hire 12/27/22; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide residents food at a safe and appetizing temperature for five residents (Residents #13, #58, #61, #63 and #64). The sample was 17. The census was 69. Review of the facility's record of food temperatures policy, revised 12/12/23, showed: -Policy: It is the policy of this facility to record food temperatures daily to ensure food is at the proper serving temperatures before trays are assembled; -Guidelines: If the food temperature falls into an unsafe range, immediately follow procedures for reheating previously cooked food. No food will be served that does not meet the food code standard temperatures. 1. Review of Resident #13's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/25/22, showed: -Cognitively intact; -Requires assistance with eating; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure six out of 10 sampled staff hired since the last survey or full inspection, received their two-step tuberculin skin test prior to or upon hire as per facility policy. The census was 69. Review of the facility's Tuberculosis, Employee Screening policy, undated, showed: -Policy Statement: All employees shall be screened for tuberculosis (TB) infection and disease, using a two-step tuberculin skin test {TST) or blood assay for Mycobacterium tuberculosis (BAMT) and symptom screening, prior to beginning employment. The need for annual testing shall be determined by the annual TB risk classification or as per State regulations; -New Employee Screening: -1. Each newly hired employee will be screened for TB infection and disease after an employment offer has been made but prior to the employee's duty assignment; -2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents and/or responsible parties were notified in a timely manner when a resident's account was within the $200.00 Social Security (SSI) limit ($5,726.00) or when the resident's account was over the SSI limit. This affected two residents reviewed who received Medicaid benefits (Residents #176 and #45). The census was 69. Review of the facility's Resident Trust Fund (RTF) policy, undated, showed: -Purpose: To establish policy and procedures for the facility RTF; -Policy: It will be the policy of the management company that the RTF is managed and accounted for in accordance with state and federal regulations. Each facility should follow the state guidelines of the payment programs using the greatest level of specificity if requirements vary in state and federal programs; -General included: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a discharge summary was completed for one resident, including a recapitulation of the resident's stay and a final summary of the resident's status at the time of the discharge, for one of one resident investigated for discharge (Resident #72). The census was 69. Review of Resident #72's medical record, showed: -admitted [DATE]; -Primary diagnosis traumatic subdural hemorrhage (brain bleed); -An order dated 11/13/23 to discharge to another long-term care facility; -A progress note dated 11/17/23, resident discharged to another long-term care facility at 12:00 P.M. with medications, via family personal car; -A discharge summary opened in the electronic medical record on 11/17/23 at 12:43 P.M., was blank. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide proper treatment and care to maintain good foot health by failing to ensure timely follow-up with a podiatrist for one resident (Resident #7). The census was 69. Review of the facility's Care of Fingernails/Toenails policy, revised February 2018, showed: -Purpose: The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections; -General Guidelines: -1. Nail care includes daily cleaning and regular trimming; -2. Proper nail care can aid in the prevention of skin problems around the nail bed; -3. Unless otherwise permitted, do not trim the nails of diabetic residents or residents with circulatory impairments; -4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin; -5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with limited mobility received services, equipment, and assistance to maintain or improve mobility as recommended by the Physical Therapist for one of three residents investigated for position and mobility (Resident #39). The census was 69. Review of the facility's Restorative Nursing Programs policy, date implemented 9/13/23 and last date reviewed 1/18/24, showed: -It is the policy of this facility to provide maintenance and restorative services designated to maintain or improve a resident's ability to the highest practicable level; -Restorative nursing program refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safety as possible. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident was seen by his/her physician within the first 30 days of admission to the facility (Resident #61). The sample was 17. The census was 69. Review of the facility's Physician Visits policy, undated, showed: -Policy Statement: The Attending Physician must make visits in accordance with applicable state and federal regulations; -Policy Interpretation and Implementation included; -The Attending Physician must visit his/her patients at least once every thirty (30) days for the first ninety (90) days following the resident's admission, and then at least every sixty (60) days thereafter; -A physician visit is considered timely if it occurs not later than ten (10) days after the date the visit was required. [...]

Inspectors wroteBased on interview and record review, the facility failed to post nurse staffing information on a daily basis, to include the total number of hours worked by categories of licensed staff, identifying Registered Nurse (RN) hours and Licensed Practical Nurse (LPN), directly responsible for resident care per shift. The census was 69. Review of the nurse staffing information, posted at the front entrance of the facility, on 1/16/24 at 6:34 A.M., showed: -The staffing sheet dated 1/12/24; -The categories included licensed nursing staff and unlicensed nursing staff for the day, evening, and night shift; -The staffing sheet did not identify the number of licensed nursing staff, LPN hours versus RN hours. During an interview on 1/19/24 at 9:51 A.M., the Director of Nurses said the Staffing Coordinator is responsible for posting the staffing information. During an interview on 1/19/24 at 10:19 A. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop policies to define the process for updating residents' code status. This failure resulted in facility staff's failure to follow one of four sampled resident's wishes for a do not resuscitate (DNR) code status and staff performed cardiopulmonary resuscitation (CPR) when the resident was found unresponsive (Resident #1). The census was 72. Review of the facility's CPR policy, dated [DATE], showed the following: -Policy: It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement guidelines regarding cardiopulmonary resuscitation (CPR); -Policy Explanation and Compliance Guidelines: The facility will follow current American Heart Association (AHA) guidelines regarding CPR. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff treated residents with respect and dignity by leaving one resident exposed during personal care (Resident #22) and by standing while assisting residents with meals. The sample size was 18. The facility census was 84. 1. Review of Resident #22's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/7/19, showed the following: -No cognitive impairment; -Unable to ambulate; -Dependent on two staff members for transfers; -Extensive assistance required for bed mobility and toileting; -Diagnoses included Alzheimer's disease, chronic lung disease, muscle atrophy and morbid obesity. Review of the care plan, dated 5/15/19 and last updated 6/19/19, showed the following: -Problem: Resident is dependent for toileting; -Goal: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care plans reflected residents' current needs by not updating them to include new/additional fall interventions. Staff also failed to address one resident's order to receive nothing by mouth (NPO), include a resident's risk of elopement and use of a wanderguard (a worn device which alerts staff of an attempted elopement) and the treatment and interventions for a resident's skin condition for four of 18 sampled residents (Residents #4, #1, #6 and #85). The census was 84. 1. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/18/19, showed the following: -Severe cognitive impairment; -Required extensive assistance from staff for transfers, toileting, personal hygiene and dressing; -Mobility devices used: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure physician orders were followed by not obtaining orders for a hand splint, the care of a gastrostomy tube (G-tube, a tube surgically inserted into the stomach to provide hydration, nutrition and medications), a suprapubic catheter (a sterile tube inserted into the bladder through the abdominal wall to drain urine) and not documenting intake for a resident with a fluid restriction for four of 18 sampled residents (Residents #1, #61, #41 and #19). The census was 84. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/10/19, showed the following: -Severe cognitive impairment; -Dependent on staff for all mobility and personal hygiene; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide and ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain adequate oral hygiene and nail care, including cleansing and trimming, for three of 18 sampled residents (Residents #1, #136 and #60). The census was 84. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/10/19, showed the following: -Severe cognitive impairment; -Dependent on staff for all mobility and personal hygiene; -Diagnoses included stroke, malnutrition, gastrostomy tube (g-tube, small tube surgically inserted through the abdomen in to the stomach to administer food and fluids) and aphasia (inability to produce and/or understand speech). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure appropriate and safe transfer techniques were used in the care of one resident (Resident #22) during one of four transfers observed. The facility also failed to prevent resident access to razors in three of four common shower rooms. This had the potential to affect all residents who were able to move freely around the facility. The census was 84. 1. Review of Resident #22's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/7/19, showed the following: -No cognitive impairment; -Unable to ambulate; -Dependent on two staff members for transfers; -Extensive assistance required for bed mobility and toileting; -Diagnoses included Alzheimer's disease, chronic lung disease, muscle atrophy and morbid obesity. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide thorough assessments, orders, monitoring and ongoing communication with the dialysis (the clinical purification of blood by dialysis as a substitute for the normal function of the kidney) center for two residents (Residents #69 and #19). Additionally, the facility had no contract with one of the dialysis providers (Resident #19). The facility identified four residents who received dialysis. Two of them were chosen for the sample of 18 and issues were found with both of them. The census was 84. 1. Review of Resident #69's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/20/19, showed the following: -Moderate cognitive impairment; -Total dependence on staff for transfers, dressing and bathing; -Incontinent of bowel and bladder; -Received dialysis; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure enough dietary staff to effectively carry out food service in a timely manner and at appropriate times. The census was 84. Review of Resident Council minutes, showed the following: -August 2019, Dietary: Resident #62 said meals start increasingly late; another resident said weekend meal service was poor; -Issues addressed on the back of the minutes with a handwritten note by the administrator did not include late and poor meal service; -September 2019, Old business, dietary issues not addressed as old business; -Dietary: Resident #62 said, They are still serving way too late and missing one or more items on his/her tray; -Issues addressed on the back of the minutes with a handwritten note by the administrator, dietary manager has been on family leave and hopes to be back soon; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to serve food that was palatable when staff failed to follow recipes for the preparation of therapeutic pureed diets. The facility identified eight residents who received pureed diets. The census was 84. 1. Observation on 11/6/19 at 10:20 A.M., of pureed ravioli and meat sauce preparation, showed the following: - [NAME] L said he/she would make eight to 12 servings of pureed ravioli and meat sauce, took four slices of bread (one slice per serving) from a bag, tore it into pieces into the blender, turned the blender on and blended until breadcrumb consistency; -Cook L added three - 4 ounce scoops of ravioli and meat sauce to the blender; [...]

Inspectors wroteBased on observation and interview, the facility failed to prevent a build up of frost and ice in the walk-in freezer by not repairing or replacing the freezer door, failed to date and cover food items in the refrigerator, keep a handwashing sink clean and ensure boxes were not stored on the floor in the freezer. The census was 84. 1. Observations of the kitchen on 11/5/19 at 10:25 A.M., 11/6/19 at 10:20 A.M., 11/7/19 at 10:58 A.M., and 11/8/19 at 12:30 P.M., showed the following: -The door to the walk-in freezer open, with an approximate 10 inch piece of rubber seal sticking out from the door, with the door unable to close. The inside shelves to the left of the door held frozen food products and were covered in a heavy build-up of frost and ice, ice on ceiling and floor and a lighter build-up of frost on the shelves and frozen food to the right of the freezer door. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff used acceptable infection control procedures during blood sugar testing and incontinence care for one resident (Resident #70) of 18 sampled residents. The facility also failed to properly label, with a resident's name, a comb and brushes left in the community shower rooms, all of which contained hairs in the teeth/bristles. The facility census was 84. 1. Review of Resident #70's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 9/20/19, showed the following: -Severe cognitive impairment; -Dependent on staff for toileting, dressing and personal hygiene; -Incontinent of bowel and bladder; -Diagnoses included diabetes, seizures and altered mental status. [...]

Inspectors wroteBased on interview and record review, the facility failed to promote and facilitate resident self-determination through support of resident choice, by failing to facilitate a resident's right to make choices about aspects of his or her life in the facility that are significant to the resident when the facility staff opened and withheld resident mail without the resident's permission (Resident #79). Staff also failed to ensure the resident was served a diet in a texture he/she could chew. The sample size was 18. The census was 84. 1. Review of Resident #79's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 10/5/19, showed the following: -Cognitively intact; -Required total staff assistance for transfers, locomotion, toileting and bathing; -Required no assistance for eating; -Dental: left blank; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide services to assure that residents maintained and/or improved their highest level of range of motion and mobility by not providing restorative therapy to two of 18 sampled residents (Residents #136 and #41). The census was 84. 1. Review of Resident #136's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/1/19, showed the following: -admission date of 8/26/19; -Severely impaired cognition; -Diagnoses included right hip fracture and other fractures; -Required total assistance from staff with bed mobility, transfers and bathing; -Required extensive assistance from staff with dressing and toilet use; -Limited range of motion (ROM) affecting one side of the body, of the lower extremity; -Received skilled therapy services, physical and occupational. [...]

Inspectors wroteBased on interview and record review, the facility failed to issue a written transfer/discharge notice to the resident and/or resident's representative, when transferred to the hospital for various medical reasons for three sampled residents (Residents #4, #1 and #56). The sample was 18. The census was 84. 1. Review of Resident #4's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, admission and discharge assessments, showed the following; -admission date of 2/4/10; -Discharge to the hospital 4/5/19; -readmission to the facility 4/13/19; -Discharge to the hospital 4/13/19; -readmission to the facility 4/22/19; -No documentation the resident and/or their representative received written notice of the resident's transfers. 2. Review of Resident #1's MDS admission and discharge assessments, showed the following: -admitted to the facility 6/19/18; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide written notice of the facility's bed hold policy to residents or their legal representatives, at the time of the transfers, for three sampled residents who were transferred to the hospital for medical reasons (Residents #4, #1 and #56). The census was 84. 1. Review of Resident #4's Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, admission and discharge assessments, showed the following; -admission date of 2/4/10; -Discharge to the hospital 4/5/19; -readmission to the facility 4/13/19; -Discharge to the hospital 4/13/19; -readmission to the facility 4/22/19; -No documentation the resident and/or their representative received written notice of the facility's bed hold policy at the time of transfer. 2. Review of Resident #1's medical record, showed the following: [...]