Baptist Homes of Shelbina

Inspectors wroteBased on interview and record review, the facility failed to ensure staff treated four residents (Residents #4, #2, #6, and #3), in a review of 10 sampled residents, with dignity and respect when Certified Medication Assistant (CMT) A spoke to the residents with a harsh and demeaning tone and with aggressive actions that resulted in the residents feeling they were being scolded and/or treated like children. The facility census was 61. Review of the facility policy, Dignity, dated 2001, showed the following: -Each resident shall be cared for in a manner that promotes and enhances his/her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem; -Residents are treated with dignity and respect at all times; -The facility culture supports dignity and respect for residents by honoring goals, choices, preferences, values, and beliefs. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide protective oversight to ensure one additional resident (Resident #33), followed facility policies regarding smoking. Resident #33, who utilized oxygen, was assessed by the facility to be a safe smoker and could smoke independently. Observation on 06/24/25 at 12:30 P.M., showed the resident outside smoking a cigarette. His/Her portable oxygen concentrator (a device that delivers oxygen) was turned on and running at three liters per minute. The resident had removed his/her oxygen tubing from his/her nose and laid the tubing across the right armrest of his/her wheeled walker. The resident held a lit cigarette in his/her right hand, approximately six inches from the oxygen tubing connected to the portable oxygen concentrator located under the seat of the wheeled walker. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain one ice machine to be free of an accumulation of debris and failed to ensure the ice machine was equipped with an air gap. The facility also failed to ensure food items were labeled, dated, covered and discarded when expired. The facility census was 56. 1. Observation on 6/23/25 at 9:12 A.M. of the ice machine located in the facility kitchen showed pink-colored debris inside the unit on the white plastic shield over the accumulated ice below. The ice machine drain was not equipped with an appropriate air gap below the unit. During an interview on 6/23/25 at 3:05 P.M., the Dietary Manager said dietary staff was responsible for wiping down the outside of the ice machine daily. The unit was deep cleaned by maintenance staff monthly. The ice machine was new and the facility just got the unit last month. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop specific control parameters for addressing Legionella (a bacterium that can cause a serious type of pneumonia in persons at risk), based on Center for Disease Control (CDC) and American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) standards. The facility did not fully implement the facility's Legionella Water Management Program policy which instructed staff how to monitor residents for Legionnaire's disease, have a water management team as described, follow ASHRAE guidelines, and have a detailed water flow map. The facility failed to ensure staff performed appropriate hand hygiene and changed gloves during the provision of care for three residents (Residents #9, #42, and #38), in a review of 16 sampled residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff treated three residents (Resident #15, #46 and #38), in a review of 16 sampled residents, with dignity and respect when a staff member (Certified Medication Technician (CMT)/Certified Nurse Aide (CNA) N spoke to residents in a harsh, stern, and hurried manner. The facility census was 56. Review of the facility policy, Dignity, revised February 2021, showed the following:-Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem;-Residents are always treated with dignity and respect;-The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values, and beliefs. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a system to consistently communicate code status for two residents (Resident #15 and #206), in a review of 16 sampled residents, and one additional resident (Resident #49). The facility census was 56. Review of the facility policy, Advance Directives, dated [DATE], showed the resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide an appropriate diagnosis for the use of psychotropic medications (medications that alter the levels of chemicals in the brain that influence mood, behavior and perception) for three residents (Residents #8, #50, #53) in a review of sixteen sampled residents. The facility failed to ensure one resident's physician (Resident #50) was made aware of a pharmacy recommendation to reduce his/her antipsychotic and failed to ensure gradual dose reductions (GDRs) were attempted, or documented as clinically contraindicated, for two resident (Residents #50 and #53). The facility census was 56. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff performed complete perineal care for three residents (Residents #7, #38 and #106), in a review of 16 sampled residents, who had been incontinent. The facility census was 56. Review of the facility policy, Guidelines for Providing Resident Care, dated 01/01/2025, showed the following:-To provide an optimum level of care for our residents;-All residents unable to adequately do Activities of Daily Living (ADL) are to have assistance with washing peri-area (genitals) each morning;-Residents who are bedfast must be given peri care and turned every two hours or more often if assessment warrants. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and secure storage of narcotic medications when staff failed to secure the narcotic medications behind two locks. The facility also failed to remove and destroy expired stock medications (over-the-counter medications used for more than one resident) from medication carts and the medication room and failed to destroy medication for one resident (Resident #23), in a review of 16 sampled residents and three discharged residents (Resident #300, #301 and #302). The facility census was 56. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to offer a bedtime snack to all residents. The facility census was 56. Review of the undated facility Bedtime Snack Policy showed the following:Policy Purpose:-To ensure that all residents of the facility receive a safe, nutritionally appropriate, and person-centered bedtime snack option consistent with their care plan, dietary needs and preferences;Policy Statement:-The facility is committed to providing bedtime snacks to residents who desire them, as part of a holistic approach to nutrition, comfort, and individualized care. Snacks are offered daily and will meet nutritional, therapeutic, and safety standards;1. Availability of Bedtime Snacks:-Bedtime snacks will be offered to residents between bedtime medication pass unless residents request a different time;-Snacks may include but are not limited to: [...]

Inspectors wroteBased on interview and record review, the facility failed to update care plans to reflect current care needs for two residents (Residents #6 and #8), in a review of 16 sampled residents. The facility census was 56. Review of the facility's undated policy, Care Plan Policy, showed the following:-Care plans will be updated by nursing and administrative staff as needed for each resident;-Within seven days after every quarterly and annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, the resident and/or durable power of attorney (DPOA) will be offered a meeting with the facility administrative staff to discuss changes and concerns;-Within that same seven-day time frame, the care plan will be updated, and the next review target date will be triggered. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two nurse aides, (NAs) (NA M and NA Z), of five NAs reviewed, completed a certified nurse aide (CNA) training program within four months of their employment in the facility. The facility census was 56. 1. Review of the facility provided list of employees hired since the last annual inspection showed NA M's date of hire was 02/26/25. Review of the facility schedule showed the following:-On 06/24/25 NA M was scheduled to work the B Hall for the 6:00 A.M. to 2:00 P.M. shift;-On 06/25/25 NA M was scheduled to work the A Hall for the 6:00 A.M. to 2:00 P.M. shift. Observation on 06/26/25 at 1:33 P.M., showed NA M provided toileting hygiene and transfer assistance to Resident #38. [...]

Inspectors wroteRefer to FL1K12. Based on observation, interview, and record review, the facility failed to obtain an order for port-a-catheter (device connected to a vein in the chest or neck by a small, thin tube/catheter with an injectable disc that can be accessed for administration of IV (intravenous) medications or fluid) care for one resident (Resident #1), in a review of one resident with a port-a-catheter, per the discharge instructions after the placement of the device. The census was 58. Review of the facility policy, IV Therapy: Central Line Management Protocol, effective 03/11/21, showed the following: -Purpose: To outline the nursing management of residents who have a central line catheter and to specify nursing responsibilities in obtaining samples; -Interdependent (requires physician order to implement); -Flushes: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff responded to call lights timely for five residents (Residents #1, #2, #3, #4 and #6), in a review of six sampled residents. Staff failed to accommodate the residents' needs for assistance, including assistance with toileting, which resulted in episodes of incontinence. The facility census was 59. Review of the facility policy titled, Nurse Call System, revised 11/15/2023, showed the following: Call escalation: -Call made, activates Certified Nurse Aide (CNA) pagers; -Repeat call goes out to CNA, at seven minutes; -Call escalates to Restorative Nurse and Certified Medication Technician (CMT) if call is not responded to within 14 minutes; -Call escalates to charge nurse at the 21 minute mark; -Director of Nursing (DON) cell phone activated at the 28 minute mark. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain an order for port-a-catheter (device connected to a vein in the chest or neck by a small, thin tube/catheter with an injectable disc that can be accessed for administration of IV (intravenous) medications or fluid) care for one resident (Resident #1), in a review of one resident with a port-a-catheter, per the discharge instructions after the placement of the device. The census was 58. Review of the facility policy, IV Therapy: Central Line Management Protocol, effective 03/11/21, showed the following: -Purpose: To outline the nursing management of residents who have a central line catheter and to specify nursing responsibilities in obtaining samples; -Interdependent (requires physician order to implement); -Flushes: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff transferred one resident (Resident #6), in a review of seven sampled residents, who required staff assistance and use of a gait belt (belt used to help safely transfer a person from a bed to a wheelchair, assist with sitting and standing, and ambulation). Both staff and the resident fell. The resident had a history of falls and a left hip fracture. The resident sustained a skin tear, muscle/ligament tears, and had increased pain after the fall. The facility census was 59. Review of the facility policy Gait Belt for Transfer dated 10/10/12 showed gait belts are provided to assist staff to safely transfer or ambulate residents. 1. Review of Resident #6's hospital discharge orders dated 12/8/23 showed the following: -Fracture of left hip; -Past medical history of stroke; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #7). in a review of seven sampled residents, remained free of significant medication error. The resident had an order for a Fentanyl patch (a powerful opiod medication for pain control). The resident became nauseated and unresponsive requiring two doses of Narcan (a medication used to reverse opioid overdose) before becoming responsive again. The resident was then transferred to the hospital for evaluation where hospital records showed the resident had two Fentanyl (narcotic pain medication) patches on the resident's skin (the resident's physician order was for one patch). The facility census was 59. The facility did not provide a policy for following physician's orders. Review of www.drugs.com showed the following regarding Fentanyl patch usage: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a licensed nursing home administrator was employed by the facility and was responsible for the management of the facility to ensure effective and efficient use of resources to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility census was 59. Review of the facility's undated job description for Job Title: Administrator showed the following: -General Statement of Duties: Responsible for the general health, welfare and safety of the residents, for maintaining sufficient personnel care of residents, and for keeping the facility in a clean and orderly condition at all times. Responsible for maintaining a cheerful homelike atmosphere;- -Supervision Received: Reports directly to the Board of Directors; -Supervision Exercised: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff responded to call lights timely for four residents (Residents #1, #2, #3 and #4), in a review of seven sampled residents. Staff failed to accommodate the residents' needs for assistance, including assistance with toileting, which resulted in episodes of incontinence for four residents (Resident #1, #2, #3 and #4). The facility also failed to ensure one resident (Resident #6)'s call light was within reach which resulted in the resident not being able to call for staff assistance when he/she hadpain. Thee facility census was 59. The facility did not provide a policy regarding call light response time. 1. Review of the Residents' Council meeting notes dated 12/5/23 showed the following: -13 residents attended; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement policies and procedures for the inspection, testing, and maintenance of the facility water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD). The facility failed to ensure nursing staff performed appropriate hand hygiene during care for four residents (Residents #23, #35, #39, and #42); failed to ensure staff wore proper personal protective equipment (PPE) when providing care to one resident in isolation (Resident #39); failed to properly clean and disinfect a mechanical lift between residents with a transmissible conditions; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff responded to call lights timely for five sampled residents (Residents #7, #16, #22, #45, and #59), in a review of 18 sampled residents. Staff failed to accommodate the residents' needs for assistance, including assistance with toileting, which resulted in episodes of incontinence. The facility census was 58. The facility did not provide a policy regarding call light response time. 1. During the group interview on 9/12/23 at 11:18 A.M., residents in attendance said the following: -Resident #43 said he/she slipped and fell in the bathroom and got up and went back to bed because he/she knew it might take 30 minutes or more for staff to answer his/her call light; -Resident #4 said staff's response to call lights depended on how many staff were working. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and update a plan of care consistent with resident specific conditions, needs, and risks for four residents (Residents #22, #35, #42, and #51), in a review of 18 sampled residents. The facility census was 58. Review of the facility's Care Plans policy, dated 3/14/17, showed the following: -Care plan meetings will be held for each resident every 90 days, or whenever there is a change, a problem, or an event that makes more frequent planning expedient; -Care plan problems/needs, goals, and approaches and the results will be documented in the resident's charts in the discipline's progress notes. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician's order for five residents (Resident #23, #34, #42, and #56), in a review of 18 sampled residents. The facility census was 58. Review of the facility's Vital Signs, Weights, and Flow Sheet policy, dated 10/18/16, showed the following: -Weights are monitored regularly and recorded on the individual flow sheet; -Variation in weights are reported to the attending physician following charge nurse assessment; -Weight changes of 5 percent in 30 days or 10 percent in 180 days are reported to the physician, and nurse's note is written, physician plan is indicated when applicable. 1. Review of Resident #45's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/6/23, showed the following: -The resident was cognitively intact; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff provided three residents (Residents #35, #39 and #44), in a review of 18 sampled residents, and one additional resident (Resident #37) the necessary care and services to maintain good personal hygiene and prevent body odor. The facility census was 58. Review of the facility policy, Care for the Incontinent Resident, dated 1/27/16, showed the following: -Peri-care will be provided to those residents who are incontinent of bladder and to maintain skin integrity and to promote good hygiene practices in a manner which is conducive to the resident's self-esteem while maintaining privacy; -Beginning in the folds of the thighs, washing front to back, wash one inner thigh with warm soapy wash cloth or disposable wipe; -Fold cloth using clean area to wash other inner thigh or use a new wipe for each wipe; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide physician ordered restorative services to assist two residents (Residents #23 and #39), in a review of 18 sampled residents, and one additional resident (Resident #37) with mobility and/or limited range of motion to attain or maintain their highest level of functioning. The facility census was 58. The facility did not provide a policy for restorative nursing therapy. 1. Review of Resident #39's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/1/23, showed the following: -The resident had severe cognitive impairment; -He/She had functional limitations in range of motion in bilateral upper and lower extremities; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three residents (Resident #8, #23, and #56), with orders for as needed (PRN) psychotropic medications, in a review of 18 sampled residents, were limited to 14 days as required, except if an attending or prescribing physician believed that it was appropriate for the PRN order to be extended beyond 14 days. The facility census was 58. Review of the facility's Psychotropic Medication policy, dated 4/26/17, showed the following: -The facility will make every effort to comply with state and federal regulations related to the use of psychotropic medications in the long-term care facility to include regular review for continued need, appropriate dosage, side effects, risks and/or benefits; -Efforts to reduce dosage or discontinue psychotropic medications will be ongoing, as appropriate, for the clinical situation; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Quality Assessment and Assurance (QAA) committee included the required members, including the Medical Director. The facility census was 58. Review of the undated facility policy Quality Assurance and Performance Improvement Plan (QAPI) did not provide information regarding members required to attend QAA meetings. Review of the facility's undated QAA Committee Information showed the following: -Meetings are held monthly (except May and December); Attendees: -Medical Director (usually attends via cell/speaker phone and is provided paperwork to follow along); -Administrator; -DON; -Therapy Director; -Infection Control Nurse/QAPI Team Coordinator; -Minimum Data Set (a federally mandated assessment instrument completed by facility staff) (MDS) Coordinator; -Care Plan Coordinator; -Activity Director; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the wireless call light system to ensure an audible alarm was annunciated with activation of the call light at the monitor, and staff carried pagers to alert them to residents' calls for staff assistance. The facility census was 58. Review of the facility's letter to the Missouri Department of Health and Senior Services regarding the facility's wireless nurse call paging system, dated 8/13/20, showed the wireless nurse call system will function in the following manner: -The resident initiates a call from their room or bathroom; -The notification is received at the nurses' station on the system computer, and a visual and audible alarm of the call is annunciated at the monitor at the computer located at the nurses' station; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a significant change status assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment, required to be completed by facility staff, for two residents (Resident #1 and #53), in a review of 18 sampled residents. This assessment should have been completed within 14 days after the facility determined, or should have determined, there had been a significant change (major decline or improvement in the resident's status) in the resident's physical or mental condition which had an impact on more than one area of the resident's health status and required interdisciplinary review and/or revision of the care plan. The facility census was 58. Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, version 3.0, showed the following: [...]

Inspectors wroteBased on observation and interview, the facility failed to safely transfer one resident (Resident #51), in a review of 18 sampled residents with a gait belt. Staff identified the resident required assistance with transfers and was at risk for falls. The facility census was 58. Review of the facility's policy, Gait Belt for Transfer, dated 10/10/12, showed the following: -Gait belts are provided to assist staff to safely transfer or to ambulate residents; -To transfer, assist the resident to a standing position by grasping the belt at the waist from underneath. Pivot the resident into the chair or bed. 1. Review of Resident #51's significant change Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 06/20/23, showed the following: -The resident was cognitively impaired; -He/She required limited assistance from one staff for transfers; [...]

Inspectors wroteBased on interview and record review, the facility failed to follow policies and procedures for immunization of residents against pneumococcal disease (an infection caused by bacteria) as required for ten of 20 sampled residents (Resident #1, #2, #12, #16, #30, #43, #45, #54, #55, and #64) and 33 additional residents (Resident #3, #4, #5, #10, #14, #17, #18, #20, #21, #24, #25, #26, #27, #29, #32, #33, #36, #38, #39, #40, #46, #48, #50, #51, #52, #53, #56, #58, #61, #62, #63, #66, #67). The facility failed to document if residents received the pneumococcal vaccine or did not receive the vaccine due to medical contraindications, previous vaccination or refusal, and failed to assess and vaccinate eligible residents with the pneumococcal vaccine with recommended doses of pneumococcal vaccine as indicated by the Centers for Disease Control (CDC) guidelines. The facility census was 67. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of practice for two residents (Residents #6 and #30), in a review of 20 sampled residents. The facility failed to ensure staff did not administer expired pain medication to Resident #6; and failed to ensure staff followed physician orders for psychotropic medications for Resident #30, and continued to administer as needed (PRN) medication after the medication was discontinued. The facility census was 67. 1. Review of the facility policy for destroying discontinued medication, updated on October 2019, showed the following: -Discontinued medication may be kept in the discontinue cabinet in the medication room for no longer than 30 days. -All discontinued medication will be destroyed by two licensed nurses within 30 days of date of discontinuation. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to safely transfer one resident (Resident #43), in a review of 20 sampled residents. The facility census was 67. 1. Record review of an undated CNA lesson plan titled, Transferring Residents, showed the following: -While in standing position prior to transfer, the resident's feet should be flat on the floor approximately 12 inches apart. -The gait belt is to be applied snugly around the resident's waist over clothing below the ribs so that the staff's fingers may grasp the belt securely. The belt must be applied securely to prevent the belt from sliding above the resident's waist. -Caution: Avoid twisting a resident's hips during a pivot transfer. Hip fractures may occur when the resident is unable to move his/her feet during the pivot. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two residents (Residents #44 and #64), in a review of 20 sampled residents, received oxygen therapy consistent with professional standards of practice and the residents' plans of care. The facility census was 67. 1. Review of the facility's policy Administering Oxygen by Nasal Cannula, dated 1/12/12, showed while administering oxygen by nasal cannula, the oxygen saturation should be monitored as needed or as ordered. 2. Review of Resident #44's Physician's Order Sheet (POS), dated 5/16/19, showed the following: -An order for continuous oxygen at 3 to 4 liters per minute (L/min); -Diagnoses included dyspnea (shortness of breath) and chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe.). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications with an error rate of less than five percent (%) for one resident (Resident #37), in a review of 20 sampled residents and one additional resident (Resident #20). There were 25 opportunities for error with three errors which resulted in a medication error rate of 12%. The facility census was 67. 1. Review of the facility policy Feeding Tube Instilling Medication, dated 10/18/18, showed the following: -Pour medication to be given; -Elevate head of the bed at least 45 degrees; -Measure the length of the tube and confirm length with length on eMar; -Flush tube with syringe filled with prescribed amount of water before administering medications; -Insert medication by syringe slowly into tube. (Note: medications may be diluted if necessary); [...]