Bernard Care Center

Inspectors wroteBased on interview and record review, the facility failed to have a licensed nurse in the facility to care for resident's basic needs for approximately five and a half hours, during the overnight shift that began on May 30, 2026. This practice had the potential to affect all residents who required skilled nursing care during the timeframe of 2:00 A.M. through 7:32 A.M. on May 31, 2026. The sample was 10. The census was 126. 1. During an interview on 6/10/26 at 9:30 A.M., the Administrator said she has been on her own for about a month with no Director of Nursing (DON). There is an interim type of nursing staff but she has never worked in long term care. They are hosting a job fair today and hopefully will get some applicants. She said they need a night nurse, that would help. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to honor the rights of residents to choose their own physician. The facility discontinued services with Physician A, who provided care to 35 residents, 31 of whom expressed a desire to continue care with Physician A. Five of the 31 residents were sampled and it was found the facility failed to coordinate continued access for care for all 5 (Residents #4, # 5, #6, #2, and #3). The sample was 6. The census was 127. Review of the facility's Resident Rights policy, dated 9/21/25, showed the following:-Purpose: To ensure that resident rights are protected;-Resident Rights Under Social Security Act: Resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' code status with Cardiopulmonary Resuscitation (CPR, an emergency procedure consisting of chest compressions if the heart stops beating or the person stops breathing) or Do Not Resuscitate (DNR, does not want CPR) were verified upon admission and documentation maintained in the medical record for 13 out of 29 sampled residents (#2, #5, #7, #9, #12, #14, #15, #20, #35, #113, #115, #120, #138). The facility census was 131. Review of the facility's Communication of Code Status policy, revised [DATE], showed:-Purpose: It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance with these rights, this facility will implement procedures to communicate a resident's code status to those individuals who need to know this information;-Policy: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment throughout the facility. The facility failed to ensure noise levels were comfortable when the overhead announcements were too loud and the door to the smoking area slammed, for two residents (Residents #108 and #79). One resident (Resident #4) had soiled briefs on the bathroom floor. One resident had a clogged toilet (Resident #11). In addition, the facility failed to provide clean and well-maintained walls, floors, doors, and windows for the 400 locked unit, 300 hall, 100 hall, 200 hall, lobby, hospitality room, and Southern dining room. The facility census was 131. Review of the facility's Safe and Homelike Environment Policy, last reviewed on 6/5/25, showed:-Purpose: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure comprehensive care plans were updated and accurate to reflect resident needs for 3 of 29 sampled residents (Residents #5, #6, and #100). The census was 131. Review of the facility's Comprehensive Care Plan policy, dated 10/21/24, showed:-Purpose: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment;-Procedure: The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure physician orders were followed by failing to obtain yearly electrocardiograms (EKG, a test that records the heart's electrical signals to check the rate, rhythm, and overall function) as ordered for eight residents (Residents #4, #13, #14, #16, #35, #75, #83 and #115). In addition, the facility did not ensure recommendations were followed for a palliative care referral for one resident (Resident #120). The sample was 29. The census was 131. Review of the Following Physician's Orders policy, revised 5/18/24, showed:-Purpose: To ensure that all physician's orders are followed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the restorative nursing program (RNP) policy and ensure residents who had limited mobility received restorative nursing services to promote and maintain the residents' highest practical wellbeing (Residents #3, #16, #75 and #83). In addition, the facility did not have a functional restorative nursing program to ensure recommended restorative nursing exercises were provided on a continual basis. The facility did not have a system in place to ensure residents received assessments and referrals for restorative therapy. The sample was 47. The census was 131. Review of the restorative nursing program policy, reviewed 4/30/24, showed:-Purpose: To provide maintenance and restorative services designated to maintain or improve a resident's abilities to the highest practicable level;-Definition: [...]

Inspectors wroteBased on record review and interview, the facility failed to maintain a system to ensure the resident trust fund account was managed in accordance with proper accounting principles by not maintaining an accurate accounting of all monies held in the resident trust fund account and by not reconciling each month. The facility also failed to ensure resident accounts did not have negative balances for three residents (Residents #88, #80 and #55). The facility managed funds for 105 residents. The facility census was 131.1. Review of the facility maintained attempted reconciliation forms for the period of 12/1/24 through 11/30/25, showed the attempted reconciliations did not reconcile to the residents' current balance at the time of reconciliation:-December 2024: -Ending balance per bank statement: $190,580.09; -Current balance per trust report: $167,812.94; -January 2025: [...]

Inspectors wroteBased on interview and record review, facility staff failed to complete an annual Minimum Data Set (MDS, a federally mandated comprehensive assessment instrument completed by facility staff) assessment for one resident (Resident #20) timely as required. The sample was 29. The facility census was 131. Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, Chapter 2, Assessments for the RAI, showed the following information: -The annual assessment is an OBRA (Omnibus Budget Reconciliation Act of 1987) comprehensive assessment for a resident that must be completed on an annual basis (at least every 366 days) unless an SCSA (Significant Change in Status Assessment) or an SCPA (Significant Correction to Previous Assessment) has been completed since staff completed the most recent comprehensive assessment; [...]

Inspectors wroteBased on interview and record review, facility staff failed to assess residents using the quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, no less frequently than once every 92 days as directed by the Resident Assessment Instrument (RAI) manual for one resident (Residents #120) out of 29. The facility census was 131. Review of the Resident Assessment Manual (RAI), dated 10/1/17, showed the Quarterly assessment is an Omnibus Budget Reconciliation Act of 1987 (OBRA) non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. As such, not all MDS items appear on the Quarterly assessment. [...]

Inspectors wroteBased on interview and record review, the facility failed to assure the resident's Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) accurately reflected the resident's status of having a life expectancy of less than 6 moths when they received hospice services (a service provided when a resident has a condition indicating a life expectancy of less than 6 months as certified by the hospice physician) for one of one hospice resident investigated for hospice services (Resident #6). The census was 131. Review of the facility's MDS policy, dated 11/6/23, showed Section J (Health Conditions) is to be completed by Nursing Staff. This section addresses any condition that impacts the resident's quality of life and functional status. Used to identify the number of health conditions that impact the resident's functional status and quality of life. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents with a mental health disorder and/or individuals with intellectual disabilities had a DA-124 Level One Screen (used to evaluate for the presence of psychiatric conditions to determine if a Preadmission Screening/Annual Resident Review (PASARR) Level Two Screen was required), as required for one of three residents sampled (Resident #113) for PASARR. The sample was 29. The census was 131. Review of Resident #113's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/28/25, showed:-Entry date: 6/24/14;-readmitted : 2/4/14;-Diagnoses included depression, psychotic disorder and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dependent residents received activities of daily living (ADL) care for four sampled residents (Residents #27, #120, #5, and #6). The sample was 29. The census was 131. Review of the facility's Nail Care policy, revised 6/26/24, showed:-Purpose: The purpose of this procedure is to provide guidelines for the provision of care to resident's nails for good grooming and health;-Policy: Assessment of resident nails will be conducted on admission and readmission to determine the resident's nail condition, needs, and preferences. Report unusual or abnormal conditions of the nails to the physician and the responsible party (curling, color changed, separation form the nail bed, redness, bleeding, pain, odor, infection). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents received proper treatment and care to maintain mobility and good foot health for five residents (Resident #128, #105, #45, #17 and #1). The sample was 29. The census was 131. Review of the facility's Podiatry (foot) Services policy, revised, 5/14/24, showed:-Purpose: It is the policy of this facility to ensure residents receive proper treatment and care within professional standards of practice and state scope of practice, as applicable, to maintain mobility and good foot health;-Policy: Foot care that is provided in the facility, such as toenail clipping for residents without complication disease processes, shall be provided by staff who have received education and training to provide this service. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure physician orders were obtained for feeding tube water flushes and to ensure staff documented the date and time tube feeding formula was hung for one of two residents sampled with feeding tubes (Resident #120). The facility census was 131. Review of the facility's Following Physician's Orders policy, revised 5/18/24, showed:-Procedure: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure pain management was provided for one of 29 sampled residents who experienced pain and reported it to staff per their policy. In addition, the facility failed to report the resident's pain to the nurse (Resident #120). The census was 131. Review of the facility's Pain Management policy, revised 6/26/24, showed:-Purpose: The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences;-Policy: The facility will utilize a systematic approach for recognition, assessment, treatment and monitoring of pain;-Recognition of pain: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident's arterial venous (AV) fistula (a surgically created connection between an artery and a vein that is accessed during hemodialysis, an invasive procedure that cleanses the blood of impurities) was assessed by a licensed nurse, for one out of one dialysis resident sampled (Resident #101). The census was 131. Review of the facility's Hemodialysis policy, last revised, 5/14/24, showed:-Purpose: The facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the residents' goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis;-Care for the resident on dialysis: [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain medications identified as to be destroyed in the 300 hallway medication room in a safe and secure location inaccessible by unauthorized staff. This affected one of two observed medication storage rooms. The census was 131. Review of the Medication Destruction policy, revised [DATE], showed:-Purpose: To ensure that medications that cannot be returned to the dispensing pharmacy are destroyed;-Policy: -Any medication that is to be destroyed is to be locked in a separate cabinet and labeled to be destroyed. No other items, medications or treatments are allowed to be stored in the to be destroyed cabinet;---Medications should not be in an unsecured area to be handled at a later time. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure pharmacy recommendations were followed up on in a timely manner for one of five sampled residents reviewed for pharmacy recommendations (Resident #2). The facility census was 131. Review of the facility's Medication Regimen Review (MMR) policy, revised 6/26/24, showed:-Purpose: The drug regimen of each resident is reviewed at least once a month by a licensed pharmacist and includes a review of the resident's medical chart;-Timelines and responsibilities for Medication Regimen Review: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was served at a palatable and appetizing temperature during tray service by failing to maintain the temperature of hot food at least at 120 degrees Fahrenheit (F) and failed to ensure food was palatable for two of 29 sampled residents (Residents #11 and #13). The census was 131. Review of the facility's dietary food preparation policy, dated 7/5/23, showed:-Food temperatures: foods will be served at proper temperature to ensure food safety;-Acceptable serving temperatures: eggs should be between 135 degrees F and 155 degrees F. Meat should be 135 degrees F;-If temperatures are not at acceptable levels and cannot be corrected in time for meal service, make an appropriate menu substitution and discarded out of temperature range foods. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to offer and vaccinate eligible residents for the pneumococcal (pneumonia caused by bacteria) vaccine for two out of five residents sampled for immunizations (Resident #28 and Resident #18). The census was 131. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain essential equipment in a safe and operable working condition by not maintaining a consistently operating elevator. This deficient practice had the potential to affect all residents. In addition, one resident (Resident #2) did not have access to his/her wheelchair while being repaired because the repair needed to occur in the lower level of the facility, and the resident did not have access to an alternate wheelchair during the repair. The sample size was 29. The facility census was 131. Review of Resident #2's face sheet, showed:-admitted on [DATE];-Diagnoses included high blood pressure, chronic atrial fibrillation (irregular heart rhythm), acquired absence of right leg below the knee, and acquired absence of left leg below the knee. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an appropriate exhaust system to remove cigarette smoke from the facility's indoor smoke room. This affected all residents who sat in the 300 Hall dining room or walked from the 300 Hall to the 400 Hall. The facility census was 131. Review of the facility's Safe and Homelike Environment policy, last revised on 6/5/25, showed:-Purpose: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment;-Environment refers to any environment the facility that is frequented by residents, including hallways and dining rooms;-General considerations: Have adequate outside ventilation by means of windows, or mechanical ventilation or a combination of the two. 1. Observations of the smoke room on 12/15/25 at 11:50 A.M. and 6:00 P.M., 12/16/25 at 11:06 A.M.,1:24 P.M. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all corridors had handrails and failed to ensure existing handrails were securely affixed to the wall. The census was 131. Review of the Facility Area Audit, Preventative Maintenance Inspection, undated, showed handrails listed as an item for staff to inspect. 1. Observation of the 100 Hall on 12/16/25 at 8:16 A.M., showed:-No railings between room [ROOM NUMBER] and the 100 hall dining room;-No railings around the perimeter of the 100 hall nurse's station;-Broken railing that pulled away from the wall outside of room [ROOM NUMBER]. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide catheter care consistent with physician orders when staff flushed the suprapubic catheter (a flexible tube inserted into the bladder used to drain urine continuously) of one of six sampled residents. The sample was 6. The census was 127. Review of facility's admission Checklist for new/readmits in Point Click Care (PCC, an electronic healthcare software program that maintains resident assessments, care planning, scheduling, medication and treatment administration, medical records), no date, showed: -If Foley catheter or suprapubic catheter is present, all orders must include: -Size of catheter; -Flush order with sterile water, 60 cubic centimeters (cc), as needed (PRN); -Diagnosis for Foley; -Catheter care every shift, to include daily dressing changes if a suprapubic catheter; -Change catheter monthly and as needed; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure personal funds withdrawn from the resident trust account were appropriately accounted for and used exclusively for three residents (Residents #36, #48 and #26). The facility failed to ensure withdrawals for personal spending were authorized by the resident and/or the resident's legal guardian, and signed off and approved by the appropriate facility staff, in accordance with the facility's policy. The facility identified 105 residents with funds handled by the facility. The census was 133. Review of the facility's Resident Trust policy, revised 11/8/23, showed: -Purpose: Complete procedures on resident trust responsibilities; -General Information Regarding Responsibilities of Holding Resident Funds: [...]

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. This facility identified 105 residents with funds handled by the facility. The census was 133. Review of the facility's Resident Trust policy, revised 11/8/23, showed: -Purpose: Complete procedures on resident trust responsibilities; -Resident trust bank reconciliation: --A reconciliation of the bank statement, checkbook, and resident trust funds module must be completed monthly. This will be completed by the facility's management company staff accountant responsible for the facility's financials; -The Resident Trust Clerk will review the monthly bank reconciliation for any outstanding checks listed that are over two months. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a homelike environment when staff served meals on Styrofoam and used plastic utensils, provided a dirty wheelchair to one resident (Resident #102), and did not clean three resident rooms (Resident #130, room [ROOM NUMBER], and room [ROOM NUMBER]). The sample was 26. The census was 133. Review of the facility's housekeeping deep cleaning policy, dated 6/29/23, showed: -Purpose: to ensure all rooms are clean; -Policy: Deep cleaning is to be completed as scheduled. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident's care plan was updated and accurate to reflect the resident's needs. This failure affected three residents, whose care plans did not identify the residents' smoking status and one resident, whose care plan did not identify medication refusals (Residents #283, #65, #64 and #18). The sample was 26. The census was 133. Review of the facility's Comprehensive Care Plans and Baseline Care Plans policy, revised 1/19/22, showed: -A licensed nurse that has been designated by the facility administration will coordinate each assessment with the appropriate participation of health professionals among the Interdisciplinary Team (IDT); -A comprehensive care plan should be completed within 14 days of admission; -A baseline care plan should be completed within 48 hours of admission; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to appropriately assess and investigate a series of falls resulting in head injuries, and to implement adequate interventions following the series of falls for one resident (Resident #36). The facility failed to ensure appropriate techniques and/or functional equipment were utilized during mechanical lift transfers for two residents (Residents #36 and #119), and to ensure staff applied and used gait belts properly during transfers or assisted ambulation for three residents (Residents #64, #102 and #39). In addition, the facility failed to ensure residents were routinely and accurately assessed for smoking safety for three residents (Residents #64, #18 and #107). The sample was 26. The census was 133. Review of the facility's Focus Risk Assessment Plan Scope/Severity of Falls (FRAPSS) policy, revised 6/29/23, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents with side rails were appropriately assessed for safety in accordance with the facility's policy, for four residents (Residents #125, #36, #30 and #46). The facility identified 11 residents as utilizing side rails. The census was 133. Review of the facility's Bed Siderails Policy, revised 6/29/23, showed: -All residents using any size siderail device on their beds will have a Restraint/Entrapment Assessment completed to determine the restraining, enabling, or hazard effect of the device. The Assessment will occur upon initial use, quarterly, and as needed if there is a significant change in the resident's condition; -Each resident using a siderail device will have a detailed history documented including the symptoms or reasons for using a device; -Using any device requires a care plan. [...]

Inspectors wroteBased on interview and record review, the facility failed to establish a system of record for all controlled drugs with sufficient detail to enable an accurate reconciliation for two out of three medication carts reviewed. This had the potential to affect all residents with controlled substance orders. The census was 133. Review of the facility's Medication Storage and Destruction Policy, reviewed 1/5/23, showed: -Narcotic and controlled drug storage; -A manual end of shift narcotic count must be completed with the oncoming nurse counting and the outgoing nurse verifying; -Because the narcotics may be stored in a number of different carts, different pairs of nurses may be conducting counts at the different carts; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food delivered to residents was palatable and at required temperatures for four residents (Residents #125, #84, #130 and #119) and additional residents who ate in their rooms on the 300 and 400 hallways. The sample was 26. The census was 133. Review of the facility's dietary food preparation policy, dated 7/5/23, showed: -Food temperatures: foods will be served at proper temperature to ensure food safety; -Acceptable serving temperatures are: meat should be higher than 135 degrees Fahrenheit (F) but preferably 160-175 degrees F, potatoes should be higher than 135 degrees F but preferably 160-175 degrees F; -Food tasting: the cook or Dietary Manager will taste food prepared before serving. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to keep the kitchen floor, walk in refrigerator, and appliances clean, and failed to ensure the ice machine had an air gap. The sample was 26. The census was 133. Review of the facility's daily and weekly cleaning schedule, undated, showed: -The floors are to be swept and mopped daily; -The food storage bins are to be cleaned weekly; -The storage racks are to be cleaned weekly; -The kitchen appliances are to be cleaned daily/weekly. 1. Observation on 4/14/24 at 8:16 A.M., showed the following: -The bulk storage room had water pooling on the ground, various trash and food debris littered the floor and beneath the area of the storage rack, and all three bulk bins had dirty lids with a powder substance; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice when they did not obtain Peripherally Inserted Central Catheter (PICC, a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart) line orders and nephrostomy tube (a tube that is directly inserted into the kidney to drain urine) orders on admission, failed to ensure that suprapubic catheter (a tube that is inserted in the lower abdomen to drain urine) care orders were in place on the Treatment Administration Record (TAR), and failed to ensure a yearly electrocardiogram (EKG, a test to diagnosis heart irregularities) was completed for one resident (Resident #64). The sample size was 26. The census was 133. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who required assistance with activities of daily living (ADLs-bathing, dressing, toileting) received necessary services to maintain adequate personal hygiene when staff left one resident soiled for an extended period (Resident #44), and when staff did not shave and provide nail care for three residents (Residents #102, #64 and #18). The sample was 26. The census was 133. Review of the facility's ADL and Documentation Policy, last reviewed 10/18/23, showed: -All nurses, aides and other employees must follow nursing standard of practice of completing ADLs; -For independent residents, ADLs must be documented two times per week; -For all other residents who are not independent, ADLs must be documented daily; -All documentation is completed in the electronic medical charting system. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received care consistent with professional standard when staff failed to identify newly acquired skin issues and obtain treatment orders for two residents (Residents #64 and #44). The sample was 26. The census was 133. Review of the facility's Skin Integrity Assessment policy, revised on 6/30/23, showed: -The purpose of this policy is to ensure that all residents are being assessed for skin integrity issues or concerns weekly and changes being reported to the physician, legal guardian, family, interdisciplinary care plan team and the wound nurse consultant. Procedure: -All residents will be assessed for skin integrity concerns weekly by the Resident Care Coordinator (RCC), wound nurse, or licensed designee; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure catheter bags (used to collect urine) remained positioned below the bladder of two residents with indwelling urinary catheters (thin tubes inserted into the bladder to drain urine), and to ensure catheter bags and catheter tubing remained off the floor. The facility's failure caused the potential for contamination and urinary tract infection. The facility identified six residents with catheters, all of whom were sampled, and problems were identified with two (Residents #64 and #36). The sample was 26. The census was 133. Review of the facility's Catheter Care policy, revised 6/29/23, showed: -Purpose: The facility will ensure any resident with a urinary catheter will be maintained to prevent infection; -Procedure included: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had appropriate physician orders for assessment/monitoring of dialysis (the clinical purification of blood as a substitute for the normal function of the kidney) access sites and to failed to maintain ongoing communication with dialysis centers for residents receiving dialysis treatment. Two residents were sampled for dialysis and problems were found for one resident (Resident #3). The sample was 26. The census was 133. Review of the facility's Dialysis policy, revised 3/18/22, showed: -Purpose: Ensure that residents who require dialysis receive such services as ordered by physician. The facility will ensure that residents who require dialysis receive such services, consistent with professional standards for practice, the comprehensive person-centered care plan, and the resident's goals and preferences. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow acceptable infection control standards when providing peri-care (cleansing of the genitals and anal area) for one resident (Resident #102) and when providing treatment for a supra-pubic catheter (a tube to drain urine that is inserted in the lower abdomen) for one resident (Resident #64) The sample size was 26. The census was 133. Review of the facility's Using Gloves policy, revised 6/29/23, showed: -When gloves are indicated, disposable single-use gloves should be worn; -When to use gloves: -When touching excretions, secretions, blood, body fluids, mucous membranes, or non-intact skin; -Gloves need to be used during removal of wound dressings; -Gloves are changed and hands are washed, new gloves donned before a clean dressing is applied; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all call lights in the facility were in working order, including a visual notification above the door and audible notification at the nurse's station. Concerns were noted in one of 17 resident rooms surveyed, affecting one of 26 sampled residents (Resident #65). The census was 133. Review of Resident #65's medical record, showed diagnoses included hemiplegia (paralysis affecting one side of the body), pseudobulbar affect (episodes of sudden or uncontrolled emotion), multiple sclerosis (MS, a chronic disease of the central nervous system causing pain and loss of fine motor function) and hypertension. Review of the resident's quarterly Minimum Data Set (MDS), a federally-mandated assessment instrument completed by facility staff, dated 1/11/24, showed: -No cognitive impairment; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #1) received his/her PRN (administered as necessary) Oxycodone (opioid narcotic used to treat moderate to severe pain) timely. The medication was available in the facility Statsafe (an emergency drug dispensing system containing multiple commonly used medications that requires a code to access), but the nurse on duty did not have the code to access the system to obtain and administer the medication when the resident requested it. Four residents were sampled and problems were found with one. This had the potential to effect any resident with an order for a medication located in the Statsafe system. The census was 128. Review of the resident's admission face sheet, showed: -admission date of 8/25/23; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed implement written policies and procedures regarding the residents' right to formulate an advance directive when staff failed to follow policies and procedures regarding accurate documenting of residents code status, for 13 of 27 sampled residents (Residents #120, #29, #76, #66, #9, #69, #65, #534, #63, #484, #81, #16, and #103). The census was 135. Review of the facility's Code Status/emergency Procedures/Medical Emergencies policy, revised on [DATE], showed: -Purpose: To outline procedures to be followed during a medical emergency, to establish guidelines for the initiation of cardiopulmonary resuscitation (CPR), and notification of emergency medical services (EMS), attending physician, administrator, Director of Nursing (DON) and legal guardian/family; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide alternate meals to residents. The facility did not have a documented alternate meal plan for six out of 27 sampled residents (Residents #16, #55, #65, #91, #74, and #103). The facility census was 135. 1. Review of the facility's resident council minutes, dated 6/23/22, showed: -Dietary: They have gotten worse. Can they have a choice between a sandwich or salad for substitutes; -Department heads in attendance included Food Services Director. During a resident council interview on 8/23/22 at 10:30 A.M., seven of seven residents in attendance who represent the resident population said if they do not like what is served during a meal, they are given a sandwich. 2. Review of Resident #16's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare and serve food under sanitary conditions when staff donned gloves without washing hands, prepared food underneath dust coated ceiling lights and peeling paint, failed to label and date food when it was removed from the original container, failed to date health shakes to ensure they were not used beyond 14 days of the thaw date, failed to air-dry dishes and failed to ensure there was an air gap for the ice machine to prevent back flow. This had the potential to affect all residents who consumed food from the facility's kitchen. The census was 135. Review of the facility Dietary - Sanitary Procedures policy, dated 1/29/2018, revised on 10/12/2021, showed: -Hand Washing and Glove Use: Guidelines for hand washing and glove use to promote safe and sanitary conditions throughout department; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure quality assurance performance improvement (QAPI) meetings consisted of the required committee members when the medical director failed to attend the facility's QAPI meetings. The census was 135. Review of the facility's QAPI plan policy, undated, showed: -Purpose of your organization's QAPI plan: -To provide quality excellence in resident care and do a route cause analysis for identified areas of concern and improvement; -Our facility written QAPI plan provides guidance for our overall quality improvement program. Quality assurance performance improvement principles will drive decision making within our organization. Decisions will be made to promote excellence in quality of care, quality of life, resident choice, person directed care, and resident transitions; -Our QAPI framework: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life when staff yelled at a resident during an interaction (Resident #107), laughed at a resident causing the resident to be angry (Resident #81), propelled the resident backwards and left the pants down exposing the resident's brief (Resident #3), assisted a resident to eat while standing, and did not keep the residents' clothes clean and free of food particles or stains (Resident #56). Other residents were observed in the dining area being assisted in eating by staff while standing. The sample was 27. The census was 135. Review of the facility's Nursing Home Residents' Rights, provided to residents upon admission, showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain written authorization to hold personal funds from residents and/or their legal guardian, for 51 out of 82 residents for whom the facility holds funds. The facility failed to ensure residents had access to their trust account during regular business hours and on the weekends (Residents #91 and #55). These deficient practices affected all residents who had a resident trust account. The census was 135. Review of the facility's Resident Trust policy, revised 9/17/21, showed: -admission requirements regarding resident trust: Upon admission, an Authorization to Hold Resident's Funds form must be presented to the resident, guardian, or legal representative and must be signed by them if they choose to have the facility manage the Resident funds; -General Information Regarding Responsibilities of Holding Funds: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure general accounting principles by failing to complete monthly account reconciliations in a timely manner. In addition, the facility failed to provide quarterly statements to residents and their representatives (Residents #91, #55, #57, and #102). This affected 82 residents whose funds were handled by the facility. The census was 135. Review of the facility's Resident Trust policy, revised 9/17/21, showed: -Purpose: Complete procedures on resident trust responsibilities; -Resident Trust Bank Reconciliation: -A reconciliation of the bank statement, checkbook, and trust funds module must be completed monthly. This will be completed by the facility's management company staff accountant responsible for the facility's financials. The reconciliation must be done by someone other than the Resident Trust Clerk; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide laundry services to ensure residents had the linen to meet their needs. In addition, the facility failed to provide a homelike environment when they served meals on Styrofoam dishes and provided plastic utensils. This affected eight resident (Residents #28, #29, #91, #74, #65, #55, #57, and #103). The sample was 27. The census was 135. 1. During the Resident Counsel interview on 8/23/22 at 10:30 A.M., seven residents who represent the resident population said the facility has run out of towels, sheets, and blankets. 2. Review of Resident #28's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/23/22, showed: -Cognitively intact; -Supervision and set up help required for dressing and personal hygiene; -Occasionally incontinent of bladder; [...]

Inspectors wroteBased on interview and record review, the facility failed to issue written transfer notices to residents and/or their representative upon transfer to a hospital when return to the facility was anticipated, for four of four residents investigated for hospital transfers (Residents #9, #63, #76 and #124) investigated for discharge notices. The census was 135. Review of the facility's resident transfer/discharge, immediate discharge, and therapeutic leave policy, revised 7/12/22, showed: -I. Reasons for discharge or transfer: C. Discharge after emergent transfers to acute care - residents who are sent emergently to the hospital are considered facility-initiated transfers because the residents return is generally expected; -II. Notice of discharge or transfer: A. Before any resident is transferred or discharged under a facility-initiated transfer or discharge, the facility must: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to issue a written bed hold notice to residents and/or their representative upon transfer to a hospital when return to the facility was anticipated, for four of four residents investigated for hospital transfers (Residents #9, #63, #76 and #124) investigated for discharge notices. The census was 135. Review of the facility's Bed Hold policy, revised 12/10/21, showed: -When a resident is discharged to the hospital or goes on therapeutic leave, the facility will provide to the resident or their legal representative, a copy of the bed hold policy; -The policy failed to direct staff to provide the resident with a bed hold notice upon transfer to a hospital. 1. Review of Resident #9 quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/7/22, showed: -admission date 7/26/21; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident assessment accurately reflected the resident's status for eight residents (Residents #50, #14, #130, #86, #28, #52, #55 and #83). The sample was 27. The census was 135. Review of the facility's Bed rails policy, dated 2/26/21, showed: -Purpose: To ensure all bed side rails in use have been evaluated for safety; -All residents using any size side rail device on their beds will have a restraint/entrapment assessment completed to determine the restraining, enabling, or hazard effect of the device. This assessment will occur upon initial use, quarterly and as needed if there is a significant change in the resident's condition; -Using any device requires a care plan. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive care plan to address residents' specific needs which included feeding assistance, behaviors, gastrostomy tube (g-tube, a surgically placed device used to give direct access to the stomach for supplemental feeding) feedings and the use of bedrails, for four of 27 sampled residents. (Residents #2, #81, #113 and #52). The census was 135. Review of the facility's Comprehensive Care Plan policy, dated 1/19/22, showed: -The purpose of this policy is ensure that the facility must develops a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment; [...]

Inspectors wroteBased on observation, interviews and record review, staff failed to ensure services being provided meet professional standards of quality care for four residents, when staff failed to document medications and weights as ordered, and failed to obtain physician orders for oxygen and diets (Residents #335, #124, #534, and #2). In addition, staff failed to document a resident's discharge for one of one resident investigated for discharge (Resident #500) who was discharged without a discharge progress note. The sample of residents was 27. The census was 135. Review of the facility's Transcription of Orders/Following Physician's Orders policy, revised 7/9/21, showed: -Purpose: The purpose of this policy is to outline procedures in accurately transcribing physician's orders and to ensure that all physicians' orders are followed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide diets and supplements as ordered to ensure residents maintained acceptable nutritional status for six residents with recent or a history of weight loss (Residents #65, #56, #132, #52, #48, and #2). The sample was 27. The census 135. Review of the facility's Weight Loss policy, revised 2/26/21, showed: -Purpose: To ensure all residents maintain acceptable parameters of nutritional status, such as body weight and protein level, unless the resident's condition demonstrates that this is not possible; -Procedure: -5% weight loss in 30 days will involve doctor notification and possible orders for dietary supplement, the dietician may be notified; -7.5% weight loss in 3 months will involve doctor notification, dietician to consult and any orders to increase dietary intake, supplements, etc; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to document the attempt to use appropriate alternatives prior to installing a side rail. The facility failed to complete an assessment of side rails to ensure correct installation, use, and maintenance including risk of entrapment from bed rails prior to installation, and failed to ensure the bed's dimensions were appropriate for the resident's size and weight, for seven of 10 residents investigated for side rail use, resulting in the bed rails of two residents being lose and ill fitting (Resident's #82, #124, #130, #86, #52, #55, and #83). The census was 135. Review of the facility's Bed rails policy, dated 2/26/21, showed: -Purpose: To ensure all bed side rails in use have been evaluated for safety; [...]

Inspectors wroteBased on observation, interview and record review, before allowing an individual to serve as a nurse aide, the facility failed to ensure the individual has met competency evaluation requirements unless the individual is in a training and competency evaluation program approved by the State, when the facility assigned three of three Nursing Assistants (NAs) employed by the facility to work on the floor in the capacity of a certified nursing assistant (CNA) when no current approved nursing instructors were in the building and when no current CNA training courses were in progress. The census was 135. Review of the Missouri Department of Health and Senior Services safety, CNA registry, CNA agency website, showed -In order to be approved to be a CNA Training Agency, the facility must meet these requirements: -Have approved instructors and clinical supervisors. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 30 opportunities for error, 3 errors occurred resulting in a 10% medication error rate (Residents #61 and #18). The census was 134. Review of the facility's Medication and Administration Policy, updated 9/17/21, showed the following: -Purpose: To ensure a process is in place for proper administration of medications, techniques of administering medications, effective monitoring of residents for adverse consequences associated with side effects to medications. To provide guidelines and systems for following procedures for medication errors including defining a medication error and levels of medication errors. To ensure therapeutic guidelines are monitored in drugs that require laboratory and diagnostic studies; -Procedure: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed ensure medical records were accurately documented in accordance with acceptable professional standards of practice when staff documented nutritional supplements administered for two residents (Residents #56 and #65), antibiotics administered for one resident (Resident #82), and a phosphorous binder administered for one resident (Resident #74), when the supplements and medications were unavailable. The census was 135. Review of the facility's Medication Administration and Monitoring Policy, revised 9/17/21, showed: -Purpose: To ensure a process is in place for proper administration of medications, techniques of administering medications, effective monitoring of residents for adverse consequences associated with side effects to medications. [...]

Inspectors wroteBased on observation, interview, and review, the facility failed to treat the resident with dignity and respect, allow the resident to retain and use personal property, and to protect property from loss or theft for one resident (Resident #120) when staff confiscated their personal cell phone and then lost the phone. The sample was 27. The census was 135. Review of facility admission packet, showed: -Residents shall be permitted to retain and use personal clothing and possessions as space permits; -Telephones appropriate to the resident's needs shall be accessible at all times; -Residents shall be encouraged and assisted, throughout his/her stay to exercise his/her rights as a resident and as a citizen; -Facility shall maintain a record of any personal items accompanying the resident up admission to the facility; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide privacy during personal care for one resident who received care in view of a roommate (Resident #83). In addition, ,the facility failed to respect the resident's right to personal privacy and confidentiality, to include medical treatment and personal care for two of 27 resident (Residents #29 and #534) when a privacy curtain was not available. The census was 135. 1. Review of the facility housekeeping process showed: -Each housekeeper is to perform a morning walk-through; -Check trash in all resident rooms and bathrooms; -Check all supplies, restock when low or empty; -Spot check floors-clean any spills or trouble areas and pick up any trash; -Identify any odors and attend to them immediately; -Check curtains for damages, and/or stains. 2. Review of the facility deep cleaning policy showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow the grievance policy, which required the facility to complete an investigation within 7-14 days and to respond to the individual making the grievance within 30 days. This affected one resident whose family member reported missing personal belongings to the facility (Resident #85). The census was 135. Review of the facility Grievance Policy, dated 6/1/17 and revised on 9/17/21, showed: -Purpose: To set forth the Resident's Right to file a grievance and the process to be followed. -Resident Right to File a Grievance; -The Facility wants to hear and address any concern of a resident. A resident or their legal representative can bring concerns to a staff member, the resident concern group, or call the compliance hotline. Additionally each Resident has the right to use the formal grievance process. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. This affected two of two sampled newly admitted residents (Residents #484 and #534). The census was 135. Review of the facility's Comprehensive and Baseline Care Plans policy, revised on 1/19/22, showed: -Section II, #2: All baseline care plan must be completed within 48 hours of admission; -Section II, #3: The Baseline Care Plan must consist of the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop the comprehensive care plan, with the interdisciplinary team and the resident, no later than 21 days after admission, for one of two sampled residents admitted within the past 30 days (Resident #534). The census was 135. Review of Resident #534's electronic medical record on 8/22/22 at 6:18 P.M., showed: -admission date of 8/4/22; -No baseline care plan; -No care plan developed; -Diagnosis listed under medical diagnosis tab: congestive heart failure (CHF, impaired heart function), atrial fibrillation (a-fib, irregular heart rhythm) and chronic obstructive pulmonary disease (COPD, lung disease). Review of the resident's electronic care plan on 8/25/22 at 7:11 A.M., showed: -Problem: 1. On 8/18/2022, patient tested positive for COVID-19, date initiated 8/18/22, revised on 8/24/22, created date 8/24/22; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate activities of daily living (ADLs) services for two of two sampled residents who required assistance with meals. (Residents #124 and #81). The census was 135. 1. Review of Resident #124's utilization review progress note, dated 5/22/22 at 12:11 P.M, showed: -The resident received physical therapy (PT)/occupational therapy (OT) four times per week; -The resident required set up assistance with eating; -Functional activities performed by therapy included transfers, safety and feeding; -He/she was not safe with ADLs. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/26/22, showed: -Cognitive status not assessed; -Rejection of care not exhibited; -Functional limitations in range of motion: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for one of one resident observed during a Hoyer (mechanical lift) transfer and one resident observed to be propelled in a wheelchair with his/her feet dragging (Residents #134 and #3). The census was 135. 1. Review of the facility's Resident Transfer with a Mechanical Lift policy, dated 4/20/21, showed: -Purpose: To ensure safe transfer of residents with the use of a mechanical lift; -Using the controls of the mechanical lift, lift the resident until their buttocks is clear from the bed, makes sure that the resident is aligned in the sling and is securely suspended in a sitting position with legs dangling over the bottom of the sling; -One staff should guide the resident's legs over the edge of the bed; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents are free of any significant medication errors for one resident (Resident #74) who missed one human immunodeficiency virus (HIV) medication, had duplicate orders for a different HIV medication, and missed a phosphorous binder medication, due to the lack of follow-up by facility staff. The census was 135. Review of the facility's Medication Administration and Monitoring Policy, revised 9/17/21, showed: -Purpose: To ensure a process is in place for proper administration of medications, techniques of administering medications, effective monitoring of residents for adverse consequences associated with side effects to medications. To provide guidelines and systems following procedures for medication errors including defining a medication error and the levels of medication errors. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to post in a place readily accessible to residents, family members and legal representatives of residents, the results of the most recent survey of the facility in a location where they would not be required to ask for staff assistance. The census was 135. Review of the facility's Nursing Home Residents' Rights, provided to residents upon admission, showed: -Residents of nursing homes have rights that are guaranteed by the federal nursing home reform law. The law requires nursing homes to promote and protect the rights of each resident and stresses individual dignity and self-determination; -Residents have the right to be fully informed of state survey reports and the nursing facility's plan of correction. Observation on 8/24/22 at 8:22 A.M., showed no survey binder available on resident halls. [...]