Belleview Care Center

Inspectors wroteBased on record review and interview, the facility failed to maintain a system to assure an accurate accounting of resident trust fund accounts was sent to the resident or resident's representative, on a quarterly basis. This deficient paractice affected four of four sampled residents, (Resident #1, #2, #3, and #4). The facility census was 84. [...]

Inspectors wroteBased on interviews and record review, the facility failed to protect one sampled resident, Resident #2, right to be free from physical abuse when Resident #1 used two hands and shoved Resident #2 to the floor. The facility census was 80. The Administrator was notified on 11/12/25 at 4:00 P.M. of the past noncompliance which began on 11/9/25. The facility staff immediately assessed and seperated Resident #2 and Resident #1, conducted an investigation, interviewed residents to ensure no others had been abused. All staff were re-trained on the facility abuse prevention policy and on monitoring residents with physical behaviors towards others. In-servicing was completed by 11/11/25. Resident #1 and #2's care plans were updated to reflect increased monitoring of both resident's whereabouts in proximity to one another. The noncompliance was corrected on 11/11/25. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect three residents right to be free from abuse when Resident #1 punched Resident #4 with a closed fist in the right shoulder and Resident #1 hit Resident #2 and Resident #3 with an open hand across the cheek. The facility's census was 82. On 03/27/25, the Administrator was notified of the past noncompliance which began on 03/25/25. Upon discovery, the facility administration immediately conducted an investigation and corrective actions were implemented. The noncompliance was corrected on 03/18/25. Review of the employee In-service sign in sheet showed staff received education on monitoring of individuals on the secure care unit, completed on 03/18/25. Review of the facility's policy titled, Abuse, Neglect, and Exploitation, dated 8/22/22, showed: [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to prepare and serve food in accordance with professional standards for food service safety when staff failed to label and date all foods, discard expired food, keep daily logs for freezer temperature, test and record dishwasher chemical sanitizer levels, seal all foods after opening, use proper hand washing, and properly store food storage containers and dishes. The facility census was 82. Review of the facility's Food Storage Policy, dated 8/12/23., showed: -All areas of food storage will be clean, dry, and maintained at temperatures as required to meet food safety requirements. -All open products will be sealed, wrapped and closed to ensure quality and prevent contamination against pests or rodents. -All outdated goods will be discarded the day after expiration date. [...]

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure staff maintained residents rights, when providing ADL (activities of daily living) cares for cognitively impaired residents in a dignified manner when the facility staff failed to ensure facial hair was removed from three of the 18 sampled residents (Resident #11, Resident #64, and Resident #21) and additionally failed to honor the bathing preferences of one cognitively intact Resident, (Resident#16). The facility census was 82. Review of the facility's Resident Rights Policy, dated 09/01/22, showed: -The resident has a right to a safe, clean, and homelike environment, including but not limited to receiving treatment and supports for daily living. Review of the facility's Grooming Residents Facial Hair Policy, dated 09/01/21, showed: [...]

Inspectors wroteBased on observation and interviews, the facility failed to maintain a safe, clean, comfortable, and homelike environment when the facility failed to maintain and replace pealing wallpaper, repair water stained ceilings, clean and replace broken furniture, repair scraped and missing paint from walls, replace broken window blinds, fix and repair loose headboards and foot boards on resident beds. and assure medical equipment is clean and stored away from residents in a common area. The facility census was 40. Review of the facility's Physical Environment Space and Equipment policy, dated 9/1/21, showed an inspection of resident care equipment will be completed routinely and as needed to maintain safe operation condition. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff did not provide complete peri care. This affected three of 18 sampled residents (Resident #10, #39 and #25). The facility census was 82. Review of the facility's policy, Activities of Daily Living, dated, 09/01/21, showed: -The facility will ensure that residents who are unable to carry out activities of daily living will receive the necessary services to maintain good grooming and personal hygiene. Review of the facility's policy, Perineal Care, dated 09/01/21, showed: [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide the care and services to attain or maintain the highest practicable physical, mental, or psychosocial well-being for three of the 18 sampled residents (#16, #47, and #48) when the facility failed to complete proper assessments, obtain a physician's order for medication to be administered to resident #47 by resident #48 and additionally failed to respect resident choice regarding showers for resident #16. The facility census was 82. The facility's Resident Rights policy, dated 9/1/22, showed: -The resident has a right to a dignified existence, self-determination, and communication with access to persons and services inside and outside the facility; -The resident has the right to self-administer medications if the interdisciplinary team determines that this practice is clinically appropriate; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff administered medications with a medication rate of less than five percent when facility staff made two medication errors out of 26 opportunities for error resulting in a medication error rate of seven percent which affected two of the 18 sampled residents (Resident #14 and #18). The facility census was 82 Review of the facility's undated policy for medication administration showed, all medications will be administered to every resident by a licensed nurse or a Certified Medication Technician (CMT) and as ordered by a physician in a safe and sanitary manner. The facility did not provide a policy for administration of eye drops. Review of the website, https://webmd.com, for artificial tears eye drops showed: - To avoid contamination, do not touch the dropper tip to the eye or or any other surface; [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure staff served food to the residents that was palatable and attractive for two of 18 sampled residents (Resident #8 and #16). The facility had a census of 82. The facility did not provide a policy on food palatability and appearance. Observation on 2/11/25 at 12:46 P.M. showed: -Alfredo noodles tasted dry and bland; -The cream pie dessert had gritty texture and was tasteless. 1. Review of Resident #16's Annual Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 11/22/24, showed: -Resident was cognitively intact; -Diagnoses included: Debility (physical weakness), heart disease, diabetes (chronic high blood sugar), depression, and lung disease. During an interview on 2/10/25 at 8:26 A.M., Resident #16 said: -Sometimes food was served cold and raw; [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that it maintained essential equipment in a safe and operable working condition. Specifically, when the large walk-in freezer had been left with a build-up of ice on the freezer floor and on the ceiling of the walk-in freezer, which left the the walk in freezer with elevated temperatures for several days, while it was defrosting. This had the potential to affect all residents due to the health risks associated with serving foods that had been thawed for an unknown period of time. The facility census was 82. The facility did not provide a policy on maintaining kitchen equipment. Observation on 2/09/25 at 10:12 A.M. showed: -Missing freezer temperature logs from 2/7 to 2/9; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assure Resident #36 and Resident #79 had access to a call light while lying in bed to prevent potential accidents by allowing these residents to summon staff as needed. This affected two of the 18 sampled Residents. The facility census was 82. Review of the Facility's Call Light Policy- Accessibility and Timely Response, dated 09/1/21, showed: -Assurance that the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. Cal lights will directly relay to a staff member or centralized location to ensure appropriate response. -Each resident will be evaluated for unique needs and preferences to determine any special accommodations that may be needed in order for the resident to utilize the call system. [...]

Inspectors wroteBased on interview and record review, the facility failed to clarify the status of Resident #10's Do Not Resuscitate Order (DNR, medical order that instructs the health care provider not to do resuscitative measures if a person's heart stops) when the resident signed the DNR authorizing no life saving measures be taken and also signed the revocation provision of the DNR, stating the resident wanted life saving measure to be taken. This affected one (Resident #10) of 18 sampled residents. The facilty census was 83. Review of the facilty's policy titled, Resident Rights Regarding Treatment and Advance Directives, dated, [DATE], showed: -This facilty supports the resident's right to request, discontinue or refuse treatment; -The facilty supports the resident's right to formulate an advance directive; [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide services that met professional standards of practice when staff failed to record the administration of medications on the Medication Administration Record (MAR) for one (Resident #13) of 18 sampled residents. The facility census was 83. Review of the facilty's policy titled, Medication Administration, dated, 09/01/22, showed: -Medications are administered by legally authorized staff as ordered by the physician in accordance with professional standards of practice; -Sign the MAR after the medication has been administered; -Document any adverse effects or refusals. Review of the facilty's policy titled, Medical Provider Orders, dated, 04/07/22, showed staff should follow all medical provider orders. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assure that two residents (Resident's #36 & #13) who needed respiratory care, was provided respiratory care consistent with professional standards of practice, when the facility staff failed to follow Physician orders for continuous oxygen therapy for Resident #36, and additionally, failed to assure that staff delivered a clean oxygen oxygen concentrator with oxygen tubing supplies for Resident #13. This affected two of the 18 sampled Residents. The facility census was 82. Review of the Facility's Medical Provider Orders Policy, dated 04/07/2022, showed: -It is the responsibility of all staff to follow all valid medical provider orders timely unless there is an emergency which would temporarily delay the implementation of the order. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #2) was free from abuse when a staff member forcibly fed the resident his/her meal when the resident expressed he/she did not want to eat. The resident was visibly emotionally upset and tearful when describing the actions to staff. This affected one of six sampled residents (Resident #2). The facility census was 82. Review of the facility provided policy Abuse, Neglect, and Exploitation, dated 8/22/22, 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, interview, and record review, the facility failed to maintain a safe/functional/homelike environment, when the facility failed to recognize and repair a leak in one resident room and one adjacent utility room, causing water to run into the room, puddle on the floor and a mold like substance to form on the ceiling and bedroom walls and in the ceiling of the utility room on the Special Care Unit. Additionally, the facility failed to adequately maintain resident safety by preventing access to the affected area. The facility census was 82. The facility did not provide a policy on wall maintenance or safety. Observation on 11/4/24 at 11:10 A.M., of room [ROOM NUMBER] showed: -The door was closed. There was no stop sign, wet floor sign, or do not enter sign; -The door knob turned easily, and the door swung open with little force; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an alleged violation of potential physical abuse was reported immediately, but not later than two hours after the allegation was made, to officials in accordance with State law, including the Survey Agency for one sampled resident (Resident #2) out of six sampled residents. The facility census was 82 residents. Review of the facility provided policy Abuse, Neglect, and Exploitation, dated 8/22/22, 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 interview and record review, the facility failed to follow their policy to maintain documentation and complete a thorough investigation of an alleged violation of resident abuse after informed by a staff member that one resident (Resident #2) reported a certified nurse aide (CNA) force fed him/her. This affected one of six sampled residents. The facility census was 82. Review of the facility provided policy Abuse, Neglect, and Exploitation, dated 8/22/22, 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, interviews and record reviews, the facility failed to assure staff followed acceptable standards of practice for one sampled resident (Residents #4) when staff did not notify the physician the resident was not taking his/her physician prescribed tacrolimus medication (an antirejection medication used after an organ transplant to ensure the body does not reject the donated organ). The facility census was 80. Review of the facility provided policy Medication Administration dated 9/1/22 showed: -Administer medication as ordered in accordance with manufacturers guidelines -Report and document any adverse side effects or refusals Review of the facility provided policy Notification of changes dated 9/1/21 showed: [...]

Inspectors wroteBased on interview, observation and record review, the facility failed to maintain a safe, clean, comfortable homelike environment by not maintaining the ceilings in the memory care unit. This has the potential to affect all residents who reside on the memory care unit, 22 residents. The faciilty census was 82. The facility did not provide a policy regarding maintaining the environment. Observations of the memory care unit on 3/20/24 at 1:50 P.M., showed: -A square, open hole, approximately 24 inches square, in the ceiling of the hall outside of room [ROOM NUMBER]. -A square, open hole, approximately 24 inches square, in the ceiling of area near the nurses' station. -Two square holes, approximately 12 inches square, covered with plastic sheeting, in the ceiling of the area leading from the nurses station to the dining area. [...]

Inspectors wroteBased on observations, interviews and record review the facility staff failed to ensure residents were treated in a dignified manner when four of eight residents (Resident #5, #6, #7, #8) had greasy, disheveled hair, body odor, and were wearing hospital gowns mid morning on 12/25/23. The facility census was 82. Review of the resident dignity policy dated 9/1/21 showed: - All staff members are involved in providing the residents care to promote and maintain resident dignity; - Staff were to groom and dress residents according to resident preference. Review of the resident showers policy dated 9/1/21 showed: - It is the practice of the facility to assist residents with bathing to maintain hygiene; - Residents will be provided showers per request or as the facility protocol; - Partial baths may be given between regular showers. [...]

Inspectors wroteBased on record review, the facility failed to provide care and treatment in accordance with professional standards of practice when licensed nurse staff failed to ensure that physician's orders were carried out for four residents (Resident #1, #2, #3, and #4) when blanks were left in the medication administration record (MAR) and treatment administration record (TAR). This affected four of eight sampled residents. The facility census was 82. Review of facility charting and documentation policy, dated 7/17, showed: -All services provided to the resident, progress toward the care plan goals, and any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to assure staff provided the necessary care and services to attain or maintain the highest practicable physical, mental, or psychosocial well-being for one of four sampled residents (Resident #3). Staff failed to monitor and assess the resident's blood glucose readings and administer insulin according to the physician's orders when Levemir insulin was ordered on 11/28/23 to be given subcutaneos daily at 8:00 P.M., The facility staff failed to give the resident the medication on 11/28/23 and 11/29/23, resulting in the resident being sent to the hospital with a critically elevated blood glucose level. The facility census was 82. Review of the facility provided policy Notification of Changes dated 9/1/21 showed: [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to answer call lights in a timely manner which affected three of 14 sampled residents, (Resident #10, #25 and #53) and failed to monitor Resident #15 to ensure he/she did not disrobe in public areas. The facility census was 56. Review of the resident's rights policy, revised 9/1/22, showed in part: - The facility will inform the resident both orally and in writing in a language that the resident understands of his/her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility; - The facility will ensure that all staff members are educated on the rights of residents and the responsibility of the facility to properly care for its residents; [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to consider concerns and recommendations from the resident council members and failed to communicate with the resident council regarding concerns as reported by four residents who participated in a group interview. The facility census was 56. Review of the facility's undated policy for resident and family grievances showed, in part: - It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal; - Prompt efforts to resolve include facility acknowledgment of a complaint/grievance and actively working toward resolution of that complaint/grievance; - The Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; [...]

Inspectors wroteBased on interviews and record review, the facility operator failed to ensure that residents had access to their funds for one resident (Resident #17) when the resident's daughter was unable to obtain available funds from the resident's account in order to take the resident out for shopping for two weeks. This had the potential to affect all residents the facility holds funds for. The facility census was 56 Review of the undated resident funds policy showed: - The facility will maintain a resident's personal funds that do not exceed $100 in a non-interest bearing account, interest bearing account or petty cash; - Residents whose care is funded by Medicaid will deposit the resident's personal funds in excess of $50 in an interest bearing account separate from the facility's operating accounts, and that credits all interest earned on residents' funds to that account. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure they established and maintained a system that ensured a full, complete and separate accounting according to accepted accounting principles and failed to establish a system that accurately provided residents with a true accounting of their statement balances and monies owed to the facility for services, which caused residents to believe their housing costs where covered, when they actually were not and the residents spent their social security checks, which should have been used for their rent to the facility. Additionally, these residents are not able to pay their rent by way of debit card, they have no access to cash, or check, and this had a negative emotional impact on two residents (Residents #25 & #51) when they worried they would now be kicked out of the facility for not paying their rent. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure they informed residents of their rights periodically during the resident's stay both orally and in writing. The facility census was 56. Review of the facility's policy on Resident Rights dated 9/1/22 showed: - The facility will inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility; - The policy did not specifically indicate when rights should be communicated with the residents. During the resident council meeting and interview with surveyors on 8/28/23 at 10:27 A.M., all four residents in attendance said: - Resident rights are not discussed at any of the resident council meetings; [...]

Inspectors wroteBased on observations, record review, and interviews the facility failed to ensure they followed their policy when they failed to indicate residents' wishes and document the residents' choice of code status in such a way to be readily accessible and understandable to staff in the event of an emergency. This affected three of 14 sampled residents (Residents #8, #3, and #209). The facility census was 24. Review of the facility's Residents' Rights Regarding Treatment and Advance Directives policy revised [DATE] 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 advance directive; - On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive; [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to provide a safe, clean, comfortable and homelike environment for all residents on the secured memory unit when the staff did not keep rooms clean, floors throughout the unit clean and in good repair, doors and walls in all the hallways and in resident rooms scuffed with missing paint. Additionally the unit, lacks a homelike environment with no decor, and has furniture being actively used by residents that is in need a replacement or repair. The facility census was 56. A housekeeping policy was not provided. Review of the facility's Resident Rights policy., dated 9/1/22 showed: -The resident has the right to a dignified existence. Observation of the memory unit on 8/27/23 at 10:22 A.M., showed: - The doors entering into the secured memory unit have papers taped to cover the windows so the residents can look out. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure staff provided a written notice of transfer or discharge to residents or their responsible parties and the reasons for the transfer, in writing and in a language they understood. The notice should include the effective date of discharge or transfer the location to which the resident is transferred or discharged ; a statement of the resident's appeal rights, including the name, address (mailing and electronic mail), telephone number of the entity which receives requests and information on how to obtain the appeal form and assistance in completing and submitting it; the name, address (mailing and electronic mail) and telephone number of the Office of the State Long-Term Care Ombudsman; [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive plan of care which included measurable objectives and time frame's for two out of the 14 sampled residents, (Resident #209 and Resident #25). The facility staff failed to implement any comprehensive person-centered plan of care that addressed the needs for resident #209 and failed to develop a care plan to address Resident #25's diagnosis of a Post-Traumatic Stress Disorder (PTSD, a disorder that develops in some people who have experienced a shocking, scary, or dangerous event). The facility census was 56. Review of the facility's Baseline Care Plan policy dated, 9/1/21 showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure they provided care and treatment in accordance with professional standards of quality when nursing staff failed to follow physician orders by not ensuring they applied tubi grips daily in the morning for one of 14 sampled residents (Resident #8) and failed to obtain an order to provide oxygen therapy for two of 14 sampled residents who were observed on oxygen (Resident #3 and #209). The facility census was 56. Review of the facility's Medical Provider Orders policy, revised 4/7/22, showed: - The facility shall use uniform guidelines for the ordering and following of medical provider orders; - Medications and/or treatments should be administered only upon the signed order of a person lawfully authorized to prescribe; [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure five of 14 sampled residents who required staff assistance (Residents #8, #10, #11, #25, and #53), 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), as well as failed to provide appropriate incontinent care for residents (#25 and #53) and failed to provide showers to maintain personal hygiene for all five of the identified residents. The facility census was 56. Review of the facility's Activity of Daily Living Policy, dated 9/1/21., showed: - The facility will ensure a resident's abilities in ADL's (Activity of daily living) do not deteriorate unless deterioration is unavoidable. - The facility will ensure the resident's ADL needs are met. [...]

Inspectors wroteBased on observation, interview and record review , the facility failed to provide an ongoing program to support residents in their choice of activities to meet the interests and well-being of the residents who reside in the facilities secured memory care unit. This affected all of the memory care residents. The facility census was 56. Review of the facilities Activity Policy, 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 psychosocial well being of each resident, as well as encourage both independence and interaction within the community. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure staff provided proper respiratory care for five of 14 sampled residents (Residents #3, #33, #47, #110, and #209) when staff failed to: effectively clean oxygen concentrator filter area, properly install oxygen concentrator filter, properly label and date oxygen concentrator oxygen tubing, properly label and date oxygen concentrator tubing setup bags, have physician's orders for oxygen administration, clean a nebulizer mask, and failed to comprehensively care plan the use of oxygen therapy. The facility census was 56. Review of the facility's undated oxygen administration policy showed: - Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences; [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide adequate staffing to meet the needs of residents by failing to: provide showers for four of the 14 sampled residents, (Residents #8, #10, #11 and #25). The facility also failed to provide care in a timely manner to Resident #25, resulting in him/her being left waiting on bed pan for an extended period of time. The facility also failed to ensure reasonable response times to call lights, resulting in extended call light wait times, which affected the four residents who attended the resident group interview. The facility census was 56. Review of the facility's undated policy on Nursing Services and Sufficient Staff policy showed: [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure staff administered medications with a medication error rate of less than 5%. Facility staff made three medication errors out of 27 opportunities for error which resulted in a medication error rate of 11%, which affected two sampled residents, (Resident #4, #25). The facility census was 56. Review of the facility's undated Insulin Pen policy., showed: - It is the policy of this facility to use insulin pens in order to improve the accuracy of insulin dosing, provide increased resident comfort, and serve as a teaching aid to prepare residents for self-administration of insulin therapy upon discharge. - Insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure staff discarded expired stock medication stored in the medication room, failed to ensure there was no food in the medication refrigerator, failed to ensure opened insulin pens and vials were dated, failed to ensure food and medications where not stored together and failed to ensure medication refrigeration was monitored for appropriate temperatures. The facility census was 56. Review of the facility's Medication Storage policy dated, 9/1/21., showed: - It is the policy of this facility to ensure all medication housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and 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. When the facility allowed dirty, black substance stained linens to be placed in resident care areas for staff and residents use, failed to monitor linens upon delivery to the clean linen rooms by the laundry staff, failed to ensure that residents, and staff had immediate access to incontinent adult briefs. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to accommodate the needs and preferences of Resident #209 when they failed to provide a chair of sufficient size and structure to accommodate the stature of the resident. Resident #209 was one out of 14 sampled residents. The facility census was 56. Review of the facility's undated Accommodation of Needs policy showed: - The facility will treat each resident with respect and dignity and will evaluate and make reasonable accommodations for the individual needs and preferences of a resident, except when the health and safety of the individual or other residents would be endangered; - The facility will make reasonable accommodations to individualize the resident's physical environment including their personal bathroom and bedroom and the common living areas within the facility; [...]

Inspectors wroteBased on record reviews and interview the facility failed to ensure they completed a Criminal Background Check (CBC) for one staff member (Certified Nurse Aide B), and the Missouri Certified Nurse Aide (CNA) Registry for eight staff members (Certified Nurse Aides B, C, D, and E); Nurse Aides A, B, C, and D) of the eight sampled staff members. The facility census was 67. Review of the facility policy, Abuse, Neglect, Misappropriation, Exploitation Policy, dated January 2019, showed: -Each center will follow any and all state specific requirements. -Potential team members shall, at a minimum, have the following screenings checks conducted: appropriate licensing board or registry check and criminal background check pursuant to company policy or state law. -The center will not retain any team member with a history of abuse or neglect if that information is known to the center. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff provided a written notice of transfer or discharge to residents and their responsible party and the reason for the transfer/discharge in writing in a language they understood. This affected three of the seventeen sampled residents. (Residents #12, #30 and # 58). The facility census was 67. Review of the facility's transfer and discharge policy, dated November 1, 2016 showed in part: Before Diversicare transfers or discharges the Resident, it shall notify the Resident and the Resident's Representative of the basis for the transfer or discharge in a language and manner they understand; and will also notify the State Long-Term Care Ombudsman. [...]

Inspectors wroteBased on interview and record review, the facility failed to inform the resident and the resident's family/legal representative of the facility's bed-hold policy at the time of transfer/discharge to the hospital. This affected three of the seventeen sampled residents. (Residents # 12, # 30, and # 58). The facility census was 67. Review of the facility's bed hold policy dated November 1, 2016 includes: - The facility will, in accordance, with Federal and State regulations, hold a Resident's bed during a temporary hospitalization or therapeutic leave. - Before the Center transfers a resident to a hospital or the resident goes on a therapeutic leave, the facility shall provide the resident or his or her representative the bed hold policy. 1. Review of Resident #12's quarterly minimum data set (a federally mandated assessment completed by facility staff) MDS, dated [DATE], showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure comprehensive care plans were developed and updated as needed to reflect urinary catheters (a flexible tube used to empty the bladder and collect urine in a drainage bag), oxygen, depression, and anticoagulants (blood thinner). This affected three residents (Resident #44, #24, and #47). Facility census was 67. The facility did not provide a policy for care plans. The Director of Nursing (DON) referred to Centers for Medicare and Medicaid Services (CMS) guidance regarding care plans. 1. Review of Resident #44's quarterly minimum data set (MDS, a federally mandated assessment completed by facility staff), dated 12/2/21, showed: -Brief interview for mental status (BIMS) score 15. This indicates no cognitive impairment. -Diagnosis include: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff provided respiratory care to two residents (Residents #24 and 58) as ordered by the physician, and failed to properly maintain clean portable oxygen concentrator tubing in room [ROOM NUMBER]. Facility census was 67. The facility did not have a policy regarding following physician orders. The facility did not have a policy regarding respiratory care. Review of the facility policy, Oxygen Tubing, not dated, did not address storage of tubing when not in use. 1. Review of Resident #24's quarterly minimum data set (MDS, a federally mandated assessment completed by facility staff) dated 11/16/21, showed: -Brief interview for mental status (BIMS) not done. This indicates severe cognitive impairment. -On oxygen therapy. -Diagnosis include: non-traumatic brain dysfunction, dementia, and anxiety. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day seven days a week who was not the Director of Nursing (DON). The facility maintained a census of greater than 60 residents and this deficiency had the potential to affect all residents. The census was 67. The facility did not have a policy regarding staff scheduling related to RN coverage. Review of facility staffing sheets showed no RN coverage, other than the DON, on the following days: -12/19/21, -11/7/21, -11/27/21, -11/28/21, -10/10/21, -10/24/21. During an interview on 1/5/22 at 3:00 P.M. the DON, Assistant DON, and the Administrator said: -The DON is utilized to provide RN coverage. -They were not aware that DON could not serve as the RN coverage due to average daily census over 60. During an interview on 1/6/22 at 3:30 P.M. the Administrator said: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases when staff failed to ensure catheter bags were kept from touching the floor for one resident (Resident #47), failed to ensure staff conducted hand hygiene during peri-care for one resident (Resident #50), and failed to ensure two staff members screened for COVID symptoms prior to working with residents (Certified Nurses Aide (CNA) F and CNA G). Facility census was 67. 1. Review of facility audit tool for Indwelling Catheters, undated, did not address catheter bags touching the floor. The facility did not provide any other catheter related policy. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with pressure ulcers received treatment as ordered for two residents (Resident #12 and #50) and services to prevent the development of pressure ulcers for one resident (Resident #12). The facility census was 67. Review of facility policy, Skin Care Guidelines, dated July 2018, showed: -All those admitted will be observed for baseline skin condition and evaluated for risk of skin breakdown. -Weekly review of the resident's skin will be completed by the nurse and documented in the medical record. -Residents will be observed by nurse aide team members daily for changes in skin condition. Changes will be reported to the licensed nurse and documented in the medical record. -Director of nursing or designee will be responsible to implement and monitor the skin integrity program. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff documented post-fall evaluations when one resident (Resident #121) suffered multiple falls. Facility census was 67. Review of facility policy, Falls, not dated, showed: -Post fall: the patient is physically assessed for injuries and medical attention rendered as needed; the physician and resident's representative are notified of the fall; the post fall evaluation is completed to assist in developing interventions to prevent future falls; the interdisciplinary team reviews post fall investigations and summarizes recommendations for interventions. Review of Resident #121's admission minimum data set (MDS, a federally mandated assessment completed by facility staff), dated 11/18/21, showed: -Brief interview for mental status (BIMS) score of 3. This indicates severe cognitive impairment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a system to monitor for weight loss for one resident (Resident #50). Facility census was 67. Review of facility policy, Weight Loss Interventions, dated December 2010, showed: -Nutritional supplements will be provided as ordered when supplements are required to maintain nutritional adequacy and/or when resident suffers from weight loss and other means of improving nutrition and/or intake. -When a resident loses three percent of more in one month, or is significantly below ideal/usual body weight, the following steps shall be taken: if the weight is questionable, re-weigh the resident; review causes for poor consumption during the weekly focus meeting; when contributing factors have been identified, appropriate interventions will be implemented; the resident will be weighed weekly for four weeks; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist one resident (Resident #50) in obtaining dental care. Facility census was 67. The facility did not have a policy to address Dental Services. Review of Resident #50's significant change minimum data set (MDS, a federally mandated assessment completed by facility staff), dated 12/15/21, showed: -Brief interview for mental status (BIMS) score of 15. This indicates no cognitive impairment. -Diagnosis include: cirrhosis (chronic liver damage leading to scarring and liver failure), renal failure, urinary tract infection (UTI, last thirty days), diabetes, thyroid disorder, fracture, cerebral palsy (congenital disorder of movement, muscle tone, or posture, due to an abnormal brain development), and depression. -No swallowing disorder. No or unknown weight loss. -No dental concerns. [...]