Big Bend Woods Healthcare Center

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, comfortable, homelike environment by failing to clean one resident's bathroom after a plumbing issue (Resident #77), failing to clean one resident's wheelchair (Resident #16), failing to clean one resident's room (Resident #37) and failing to keep temperature logs on five residents with personal refrigerators (Resident #11, Resident #48, Resident #17, Resident #4 and Resident #6) The sample was 20. The census is 90. Review of the facility's 100 hall housekeeping checklist, undated, showed;-Sweep/mop soiled closets wipe walls and reduce odors;-Empty trash cans;-Dust top of rooms, light fixtures, nightstands, counter tops, dresser, dispensers, and window sills;-Clean and disinfect sinks, beds. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate less than 5%. Out of 31 opportunities observed, five errors occurred, resulting in a 16.13 % error rate. (Resident #84 and Resident #86). The census was 90. Review of the facility's Medication Administration policy, dated November 2021, showed:-To administer the following: Right medication; Right dose; Right dosage form; Right route; Right resident; and Right time;-Read the Medication Administration Record (MAR), for the ordered medication dose, dosage form, route, and time;-Verify the pharmacy prescription label on the drug and the manufacturer's identification matches the MAR;-If there is a discrepancy, check the original physician's orders and notify the pharmacy; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective infection prevention and control program when laundry staff failed to keep dirty and clean areas separate. Trash was transported through the folding area and clean linen carts. The staff moved back and forth, handling items from washer to dryer and sorting table without hand hygiene. In addition, the facility failed to keep one resident's indwelling catheter bag off the floor (Resident #80). The sample was 20. The census was 90. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the call system on the 100 hall adequately functioned with lights outside of resident rooms and sounded at the call system panel at the nurse's station. The sample was 20. The census was 90. Review of the facility's Call Light policy, revised 8/1/18, showed:-Purpose: To respond to resident's request and needs;-Procedure included answer call lights promptly;-The policy did not provide guidance for ensuring functionality of the facility's call system. 1. During a group interview on 9/10/25 at 2:26 P.M., three out of six residents, whom the facility identified as alert and oriented, said their rooms are on the 100 hall. They said they wait for long periods of time for staff to respond to their call lights. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect a resident's right to be treated with dignity and respect when staff entered the resident's room without the resident's or resident's representative's consent and removed personal belongings (Resident #9). The sample size was 20. The census was 90. Review of the facility's Resident Rights and Dignity Protocol, reviewed January 2024, showed:-Protocol: The facility recognizes the resident right to a quality of life that supports privacy, confidentiality, dignity, independent expression, choice and decision making consistent with State law and Federal regulation. Review of the facility's New Resident Information, required for signature within 24 hours of admission, showed:-Room Search Protocol. Revised November 2023; -Purpose: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide reasonable accommodation of individual needs and preferences by failing to ensure the call light was in reach for one resident (Resident #37). The sample was 20. The census was 90. Review of the facility's Call Light policy, dated, 8/1/18, showed:-Purpose: To respond to resident's requests and needs;-Procedure: Answer call lights promptly; Determine resident's request; Listen to resident for further requests and needs; Respond to request; Assist resident as needed to a comfortable position and with call light within reach. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure services provided met professional standards by failing to include blood pressure parameters for two residents (Resident # 69 and Resident # 84), failing to ensure a nutritional supplement order had the specific type of nutritional supplement and the amount to be given included in the physician order for one resident (Resident # 87) and failing to apply tubi grips (elasticated bandage that provides continuous support) for one resident (Resident #20). The sample size was 20. The census was 90. Review of the facility's Medication Administration policy, dated, November 2021, showed:-To administer the following: Right medication; Right dose; Right dosage form; Right route; Right resident; and Right time;-Perform necessary assessments prior to administering specific medications; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents requiring assistance with ADLs (activities of daily living) received the necessary services to maintain adequate personal hygiene in accordance with their needs and preferences (Residents #37, #48, and #71). The sample was 20. The census was 90. Review of the facility's Personal Care Needs policy, reviewed 1/2024, showed:-Protocol: The facility strives to promote a healthy environment and prevent infection by meeting the personal care needs of the residents. The facility also provides the needed support when the resident performs their ADLs. The interdisciplinary plan of care (IPOC) will address the individual needs and preferences of the resident. Personal care and ADL support will be provided according to the resident plan of care. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure adequate nutritive value, taste and texture for pureed foods (a very smooth blended food like pudding or mashed potatoes) for three out of five observations. This deficient practice affected the three residents who ate pureed meals at the facility. The census was 90. Review of the Spring/Summer Menu Cycle, showed on 9/11/25, lunch consisted of roasted ham slices, baked sweet potatoes, mixed vegetables and pineapple delight dessert. Observation and interview on 9/11/25 at 11:50 A.M., showed the Dietary Manager (DM) prepared pureed ham for three residents. She added three, four-ounce slices of ham to the blender, eight ounces of juice from the ham and one slice of bread. She blended the mixture for approximately one minute and added it to the serving pan. She said she always tasted pureed foods before serving. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two residents, one with cognitive impairment, did not engage in sexual activity (Resident #1 and Resident #2). The sample was four. The census was 88. The Director of Nursing (DON) was notified on 3/19/25 at 12:40 P.M., of the past non-compliance, which occurred on 3/6/25. The facility provided in-servicing for all staff regarding the facility's abuse and neglect policy with emphasis on sexual abuse. The facility also updated Resident #1's care plan. The deficiency was corrected on 3/11/25. Review of the facility's Abuse, Neglect, Misappropriation of Resident Property Policy, dated 8/24, showed the following: -The Administrator has primary responsibility in the facility for implementation of the abuse and neglect program; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for three residents (Resident #77, Resident #48, and Resident #17). Resident #77 and Resident #48 had a decline in ability to ambulate. Resident # 48 also had a hand contracture, with an order for a splint that was not applied in accordance with the Physician Order Sheet (POS) and care plan. Resident #17 had a hand contracture and no splint use was addressed on the POS and care plan. Additionally, the facility failed to develop resident care policies for restorative services, based on professional standards of practice, including designating who may provide specific treatments. The sample was 18. The census was 86. [...]

Inspectors wroteBased on interview and record review, the facility failed to designate a person to serve as the Director of Dietary with the appropriate certification, when a consultant Registered Dietician (RD) was not employed full-time with the facility. This had the potential to affect all residents who consume meals at the facility. The census was 86. Review of the facility's director of dietary job requirements showed: -Qualifications: Certified Dietary Manager(CDM), Certified Food Protection Professional (CFPP) certification or registration as dietetic technician. During an interview on 2/8/24 at 11:21 A.M., the Administrator said the RD is not employed full time and is contracted. The Director of Dietary does not have the required qualifications. She would expect for the Director of Dietary to be certified for food handling.

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 (RTF) reconciliations. This facility identified 77 residents with funds handled by the facility. The census was 86. Review of the facility's Resident Fund Management Service (RFMS) policy, revised 5/1/20, showed: -Protocol: The facility will safeguard and manage resident funds in accordance with state regulation; -Procedure included: -All written accounts of the residents' funds shall be reconciled monthly and a written statement showing the current balance and all transactions shall be given to the resident, his/her designee, guardian and conservator, or conservator on a quarterly basis; -The policy did not provide guidance for follow-up on outstanding checks. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to make prompt efforts to resolve grievances when the facility did not file the grievance and/or the resolution for two residents (Resident #17 and Resident #16). The facility failed to make information on how to file a grievance available to the residents, notify residents individually or through postings in prominent locations throughout the facility of the right to file grievances orally or in writing, the right to file grievances anonymously, and the contact information of the Grievance Official with whom a grievance can be filed. In addition, the facility failed to have access to the grievance box that was locked and located in the dining room with grievances in the box. The sample was 18. The census was 86. Review of the facility's undated Grievance Committee Policy and Procedure, showed: -Purpose: [...]

Inspectors wroteBased on interview and record review, the facility failed to check for a federal indicator (identifies when an employee who has ever held a Certified Nurse Aide (CNA) certificate has ever been found to have abused, neglected, or misappropriated resident property) through the state Nurse Aide (NA) registry prior to hiring a new employee, in accordance with the facility's abuse policies, for four of 10 employee files reviewed. The census was 86. Review of the facility's Abuse, Neglect, Exploitation, Misappropriation of Resident Property policy and procedure, revised 9/12/18, showed: -Policy: The facility will follow state and federal guidelines on abuse, neglect; -Screenings included: -1. Prior to hiring a new employee, the facility will: -a. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an ongoing activity program based on resident preferences, to support residents in their choice of activities and meet the needs of the residents. The facility failed to accommodate resident preferences and accommodate the residents' physical needs, to include hearing and vision difficulties. When concerns were brought to administration regarding the noise level in the dining room, no interventions were put in place and activities were continued in the dining room. The resident council representatives reported when activities are held in the dining room, it is too loud and it is hard to hear, and some residents have stopped going to activities when they are held in the dining room due to the noise level. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident receives assistance to prevent accidents, for three residents observed to be propelled down the hall in a wheelchair with their feet dragging (Residents #37, #14, and #86). In addition, the facility failed to use a gait belt to transfer one resident observed to be transferred from the bed to wheelchair (Resident #19). 1. Review of Resident #37's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 11/23/23, showed: -Severe cognitive impairment; -Does the resident use a wheelchair or a scooter: Yes; -Diagnoses included dementia. Review of the resident's care plan, in use at the time of the survey, showed: -Focus: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents (Residents #16, #31, #56, #69, and #82) received room trays with food that was palatable and at the required temperatures for safe consumption. The sample was 18. The census was 86. Review of the facility's Meal Service Temperatures policy, revised 1/2019, showed: -Purpose: To ensure appropriate food temperatures during meal service and to ensure appropriate food holding temperatures. To comply with federal and state regulations governing food meal service; -Policy: Meal temperatures shall be monitored by the Director of Dietary and the cooks on a daily basis. Hot food shall be cooked or heated to a temperature above 165 degrees. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure staff were following proper hand hygiene procedures when serving food and assisting residents with meals. Further, the facility failed to ensure oversight when a resident used a drink cup to scoop ice from a community ice bucket in the dining room. The sample was 18. The census was 86. 1. Observation of the main dining room during the lunch meal on 2/5/24 at 12:24 P.M., showed Clinical Supervisor C and the Wound Nurse helping to make up and pass meal trays to residents in the dining room. Clinical Supervisor C and the Wound Nurse repeatedly served multiple resident trays with no hand hygiene in between serving the residents. Neither the Clinical Supervisor nor the Wound Nurse wore gloves as they touched the residents' plates to put them on the table. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure third party liability (TPL) forms were completed within 30 days for the final accounting for residents who expired. This affected one of two sampled residents who expired and had money in their accounts (Resident #142). The census was 86. Review of the facility's Resident Fund Management Service (RFMS) policy, revised [DATE], showed: -Protocol: The facility will safeguard and manage resident funds in accordance with state regulation; -Procedure included: -Upon the death of a resident, the operator shall contact the Department of Social Services (DSS), MO HealthNet Division, TPL Unit, to determine if the deceased resident is a MO HealthNet participant or has been a recipient of aid, assistance, care, services, or if the resident has had moneys expended on his/her behalf of DSS. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to protect the resident's right to privacy during personal care for one of two residents observed to be provided care, when the staff exposed the resident to his/her roommate during care (Resident #19). The census was 86. Review of the facility's resident's rights, provided to the resident during the signing of the admission packet showed: Resident [NAME] of Rights - Missouri: -Each resident shall be treated with consideration, respect and full recognition of his/her dignity and individuality, including privacy in treatment and care of his/her personal needs. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a clean, comfortable and homelike environment for all residents when staff failed to ensure resident rooms were without odor and floors without sticky substances (Residents #6 and #73). The sample was 18. The census was 86. Review of Housekeeping Checklist for Split Hall, the hall in which Resident #6 and Resident #73 reside, showed the following tasks are to be completed by the housekeeper assigned daily: -For Offices, Activity Room, Break Room and rooms 119-126, 200 bathroom, rooms 219-226, and Extra Rooms; -Empty trash cans, wipe trash cans out; -Dust top of rooms, light fixtures, nightstands, counter tops, dressers, dispensers, window sills; -Clean and disinfect sinks, beds, and high touch areas and items (ex. Door/knobs, remotes, etc.); -Check and restock dispensers; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice when staff failed to implement interventions to address a pressure ulcer and a history of falls for one resident (Resident #61). In addition, the facility failed to ensure one resident with a skin rash received an antibiotic medication, as ordered by the resident's physician (Resident #31). The sample was 18. The census was 86. 1. Review of Resident #61's medical record, showed diagnoses included stroke, anxiety disorder, dementia, traumatic brain injury, and epilepsy (seizure disorder). Review of the resident's electronic Physician Order Sheet (ePOS), showed an order, dated 1/2/24, for fall mats while in bed, check every shift for placement in the morning for safety. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who required assistance with activities of daily living (ADLs) received personal care and bathing assistance in accordance with their needs and preferences (Residents #31 and #16). The sample was 18. The census was 86. Review of the facility's Personal Care Needs policy, undated, showed: -Protocol: The facility strives to promote a healthy environment and prevent infection by meeting the personal care needs of residents. The facility also provides the needed support when the resident performs their ADLs. The interdisciplinary plan of care will address the individual needs and preferences of the resident. Personal care and ADL support will be provided according to the resident plan of care. Personal care and support include but is not limited to the following: -Bath/shower; -Grooming/dressing; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional standards and failed to ensure drugs and biologicals were in locked compartments for one medication cart not currently in use and stored on a resident hall. The census was 86. Review of the facility's Medication Storage in the Facility policy, dated November 2012, showed medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the suppliers. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel or staff members lawfully authorized to administer medications. Observation on 2/5/24 at 10:46 A.M., 2/6/24 at 6:49 A.M., and 2/7/24 at 5:38 A.M., showed a medication cart located near room [ROOM NUMBER]. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records, including the documentation of administration of medications and transposition of accurate skin assessments, for three of 18 residents sampled (Residents #20, #3, and #37). The facility census was 86. Review of the facility's Episodic and Narrative Documentation Policy, revised 1/5/22, showed: -Documentation will occur in the Nurse's Progress notes to reflect a change in status, event, or notification of a responsible party or physician; -A single narrative entry will occur for the following episodes, including but not limited to: admission, change in condition, body system data collection, departure or return from medical leave, and resident responses to treatment; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to adhere to general infection control principles when staff provide resident care. Facility staff failed to maintain proper and effective infection control practices while providing incontinence care for one resident (Resident #19), and by exposing a wound dressing to possible infectious organisms for another resident (Resident #37). The resident sample was 18. The facility census was 86. Review of the facility's Care of Incontinent Resident Policy and Procedures, dated 1/2022, showed: -Purpose: To have residents clean and dry. -Procedure: Wash hands. Apply gloves. Remove excess feces and urine with brief, pad, or tissue as indicated. Remove gloves and wash hands or use alcohol-based gel. Apply clean gloves. Spray perineal wash on wet washcloth and cleanse with wet washcloth, or cleanse with wet, soapy washcloth. 1. [...]

Inspectors wroteBased on observation and interview, showed 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. The survey binder was located behind the reception desk and not accessible without having to ask staff to provide the results. The census was 86. Observation on 2/5/23 at 9:00 A.M., 2/6/24 at 11:37 A.M., 2/7/24 at 6:26 A.M., showed a sign located in the front lobby recent state survey results kept at front desk. No survey binder observed on the front desk. Observation on 2/7/24 at 6:28 A.M., showed the Director of Nursing (DON) obtained the survey binder from behind the front desk. Review of the binder, showed the results of the most recent survey of the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify a representative of the State Long-Term Care (LTC) Ombudsman of resident transfers and discharges. The census was 86. Review of the facility's Admission, Discharge, Transfer Communication policy, undated, showed: -Purpose: To communicate admissions, discharges, and transfers to the Ombudsman monthly; -Policy: The facility will communicate all admissions, discharges and transfers via email or fax with the Ombudsman monthly; -Procedure: -During the first working week of the month the facility will print the admissions, discharges, and transfers for the previous month; -The facility will fax and/or email the report to the Ombudsman; -The facility will maintain the report, fax confirmation and/or email sent receipt of communication with the Ombudsman. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure their policy regarding the provision of basic life support and cardiopulmonary resuscitation (CPR, a lifesaving technique useful in which someone's breathing or heartbeat has stopped) provided guidance for staff in the event of a resident showing obvious clinical signs of irreversible death, and to provide guidance to ensure staff who provided CPR were certified in performance of CPR. The facility failed to ensure staff followed the facility's policy to correctly identify a resident's code status and to initiate CPR when one resident was found unresponsive with clinical signs of irreversible death (Resident #2). The sample was 13. The census was 83. Review of the facility's Initiating and Identifying CPR policy, undated, showed: -Purpose: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to have a process to ensure Certified Nurse Aides (CNAs) reported new or worsening skin conditions and soiled or missing dressings to the nurse when identified. In addition the facility failed to ensure nurses applied treatments to wounds with soiled or missing dressings timely, completed weekly skin assessments and ensure treatments were applied as ordered. The facility identified 13 residents with pressure ulcers. Of those 13, six were included in the sample and problems were found with all six. In addition, the survey team identified three residents with new pressure ulcers, not identified by the facility. (Residents #19, #224, #46, #63, #51, #45, #3, #22 and #55). The census was 75. The administrator was notified on 5/11/21 at 3:09 P.M., of an immediate jeopardy (IJ) which began on 5/3/21. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to notify one resident's (Resident #374) physician of a critical lab result and that resident was later admitted to the hospital for a related condition. The facility failed to administer medications per facility policy for one resident (Resident #46) and obtain orders to maintain one resident's peripherally inserted central catheter (PICC, a thin flexible tube that is inserted into a vein in the upper arm and guided into a large vein above the right side of heart. Used to give IV fluids and medications) (Resident #51). The sample was 18. The census was 75. 1. Review of the facility's Notification of Resident Change in Condition policy, updated 8/1/18, showed: -Protocol: The facility's clinician's will notify the physician and family or legal representative if there is a change in the resident's condition; -Procedure: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents and/or responsible parties were notified in a timely manner when a resident's account was within the $200 social security (SSI) limit. This affected seven of eight residents who were either over the SSI limit or within $200 of the SSI limit (Residents #500, #501, #502, #503, #504, #505 and #506). The census was 75. Review of the facility's policy regarding resident funds (RFMS), revised on 5/1/20, showed when the resident's account reaches within the $200 limit set by the state of Missouri, the business office manager (BOM) or designee will utilize the RFMS letter and send to appropriate party. The policy did not have a time of when the BOM should send the notification. 1. Review of Resident #500's trust account (a Medicaid recipient), showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure they maintained a surety bond for the resident trust fund account in the amount of one and one half times the average monthly balance for the past 12 months. The census was 75. Review of the facility's policy regarding resident funds (RFMS), revised on 5/1/20, showed no instructions on how to monitor the facility's surety bond to ensure it was sufficient. Review of the resident trust account for the past 12 months, from April 2020 to March 2021, showed an average monthly balance of $147,000. (This would yield a required bond in the amount of $220,500 (one and one half times the average monthly balance)). Review of the bond report for approved facility bonds by Department of Health and Senior Services (DHSS), showed an approved bond of $120,000, dated 1/30/15. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to establish and implement a grievance policy to ensure the prompt resolution of all grievances, that included the grievance official receiving and tracking grievances through to their conclusion. The facility census was 75. Review of the facility's Resident/Patient/Family grievance policy, dated 1/14/19, showed the following: -Protocol: A resident/patient and/or family member has the right to voice grievances without discrimination or reprisal. Such grievances include those with respect to treatment which has been furnished as well as that which has not been furnished; -The facility will provide residents/patients and their family members with prompt efforts to resolve grievances, including those with respect to the behavior of other residents/patient and/or staff; -Procedure: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy by failing to thoroughly investigate concerns made by family members on behalf of two residents regarding alleged mistreatment by staff members (Residents #15 and #379). In addition, the facility failed to ensure new employees did not have potential contact with residents prior to conducting criminal background and the employee disqualification check for three of nine sampled staff. The census was 75. Review of the facility's abuse prevention policy dated 2/19, showed: -Prevention and reporting: The administrator has primary responsibility in the facility for implementation of the abuse/neglect program; -The facility will follow all state and federal guidelines on preventing abuse, neglect, mistreatment, exploitation and misappropriation of property. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who are unable to carry out activities of daily living (ADLs) received services to maintain good personal hygiene and grooming. The facility failed to provide thorough perineal care (peri-care, cleansing from the front of the hips, between the legs and buttock and back of the hips) to one resident (Resident #55), the facility also failed to ensure one resident (Resident #22) maintained trimmed toenails, the facility also failed to ensure resident showers had been completed for two residents (Resident # 224 and Resident #69). The sample size was 18. The census was 75. 1. Review of the facility care of incontinent resident policy and procedure, reviewed 1/2020, showed: -Purpose: To keep residents clean and dry; -Policy: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff implemented interventions consistent with a resident's individual needs in accordance with their care plan to eliminate the risk and/or reduce the risk of an accident, and to ensure staff performed neurological assessments and fall investigations in accordance with the facility's policy, for five residents (Residents #37, #69, #15, #20 and #384). The sample was 18. The census was 75. Review of the facility's Falls Programs Policy and Procedure, reviewed January 2020, showed: -Purpose: To identify all residents who have a high risk for falls and to ensure adequate interventions are in place to prevent a major injury; -Policy: All residents will be evaluated to assess for fall risk on admission/readmission. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate treatment and services to prevent urinary tract infections (UTIs) by failing to adequately assess and report changes regarding an indwelling urinary catheter (a tube inserted into the bladder for the purpose of continual urine drainage) for one resident (Resident #224), and by failing to provide appropriate indwelling urinary catheter positioning for three residents (Residents #51, #19 and #59). The facility identified four residents as having indwelling urinary catheters. All four residents were chosen for the sample and problems were found with all four. The sample was 18. The census was 75. Review of the facility's indwelling urinary catheter care policy, dated January 2020, showed: -Procedure: -Provide perineal care (peri-care) first prior to catheter care; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy for hemodialysis (dialysis, the mechanical treatment of blood to clean it of impurities and excess fluids when the body's kidneys are not working properly) by failing to consistently assess residents' shunts (the connection from a hemodialysis access point to a major artery) and/or fistulas (a surgical connection made between an artery and a vein used for hemodialysis), failing to consistently communicate with the dialysis units and failing to ensure residents wore an identification bracelet showing in which arm the shunt/fistula was located. The facility identified two residents as receiving dialysis. One resident (Resident #15) was sampled, one resident was selected as an expanded sample (Resident #382) and problems were identified with both residents' care. The sample was 18. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents using bed/side rails, had adequate assessments to determine the side rails were appropriate and safe to be used and/or had physician's orders. The facility identified 17 residents that utilize side rails. Four residents were sampled for the use of side rails (Residents #13, #19, #69, and #224), two identified by the facility as using side rails (Residents #19 and #224) and two who had side rails but not identified by the facility as having side rails (Residents #13 and #69). The sample was 18. The census was 75. Review of the facility's Bed Rails policy, dated 11/27/19, showed: -The facility will attempt to use appropriate alternatives prior to installing a side rail or bed rail. If a bed/side rail is used the facility will verify correct installation, use, and maintenance of bedrails; -Protocols: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nursing staff with the appropriate competencies and skill sets were used to attain or maintain the highest practicable physical, mental, and psychosocial well-being for each resident. The facility failed to ensure that nursing staff are able to demonstrate competency in skills and techniques necessary to care for residents, by failing to conduct weekly skin assessments, report discovery of new wounds in a timely manner, and provide appropriate wound care. In addition, the facility failed to ensure all staff, including contracted agency staff, were adequately trained and informed of facility policies and expectations per acceptable nursing standards. The census was 75. 1. Review of the facility assessment tool, reviewed [DATE], showed: -Staff: -Registered Nurse (RN); -Licensed Practical Nurse (LPN); [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure eight out of nine randomly selected certified nurse aides (CNA), who worked at the facility for more than one year, had the total required annual 12 hours of resident care training. The census was 75. Review of the facility assessment, last reviewed 8/27/20, showed: -Staff education/training and competencies: -Required in-service training for nurse aides training must: -Be sufficient to ensure the continuing competence of nurse aides, but be no less than 12 hours per year; -Include dementia management training and resident abuse prevention training; -Address areas of weakness as determined in nurse aides' performance reviews and facility assessment and may address the special needs of residents as determined by the facility staff members; -Care for cognitively impaired residents; [...]

Inspectors wroteBased on interview and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation. The controlled substance shift change count check sheets were missing documentation for four of the four facility medication carts. The facility also failed to secure narcotics in two out of two medication rooms. The census was 75. Review of the facility's controlled substances policy, dated May 2019, showed the following: -Policy: Medications classified by the FDA as controlled substances have high abuse potential and may be subject to special handling, storage, and record keeping; -Only authorized nursing personnel and pharmacy personnel have access to medication. The Director of Nursing is responsible for the control of these medications; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to administer medications with a less than five percent medication error rate. Out of 26 opportunities for error, three errors occurred, resulting in an 8.66% medication error rate for two of six sampled residents (Residents #12 and #59). The facility census was 75. Review of facility's medication administration policy, last revised on 5/1/11, showed the following: -Purpose: To administer the following: Right medication; Right dose; Right dosage form; Right route; Right resident; Right time; -Read the Medication Administration Record (MAR) for the ordered medication, dose, dosage form, route, and time; -Verify the correct medication, dose, dosage form, route, and time again by comparing to MAR before administering; -Document the following as applicable: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional standards in two out of two medication rooms, two out of two treatment carts, one out of one insulin cart and four out of four medication carts. The census was 75. Review of the facility's medication storage in the facility policy, dated May 2019, showed the following: -Policy: Medications and biologicals are stored safely, securely, and properly, following the manufacture or supplier recommendations. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications; -Medications are not to be transferred medications in containers in which they were received; [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure all meals met the needs of residents in accordance with established national guidelines, by providing an alternative menu not reviewed or approved by the registered dietician (RD). The census was 75. Review of the menus and recipes, prepared by the Registered Dietician (RD), dated 5/3/21 through 5/13/21, showed the meals met recommended dietary requirements. No alternative menu options were documented by the dietician. Review of the facility's menus, prepared by the Dietary Director (DD), dated 5/3/21 through 5/13/21, showed the RD's prepared menu available for lunch and dinner. An alternative meal option available for lunch and dinner, not approved by the RD. Review of the dinner menus for 5/5/21, showed: -RD menu: cup of soup, egg salad on croissant, pickled beets, and chilled peaches; -DD menu: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident's medical records were accurate, kept confidential and secure in accordance with accepted professional standards and practices for one out of six sampled residents (Resident #19). This had the potential to affect all residents. The census was 75. Review of the facility's Confidentiality and Non-disclose Agreement, undated, showed the following: -The facility's information systems contained confidential records pertaining to the business operations, the residents, business associates, health care professionals and employees; -Employees were expected to protect data in accordance with current Health Insurances Portability and Accountability Act (HIPPA) regulations and facility policies governing the access, use and disclosure of protected health or facility information; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff completed routine inspection of bed frames, mattresses and bed/side rails as part of a regular maintenance program to identify areas of possible entrapment for four residents (Residents #13, #19, #69, and #224) with side rails to reduce the risks of accidents. The facility identified 17 residents with side rails in use. Residents #13 and #69 were not identified by the facility as having side rails. The sample was 18. The census was 75. Review of the FDA (Federal Drug Administration) documents, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated 3/10/06, showed bed rails, also called side rails, may be used as a restraint, reminder, or assistive device. Evaluating the gaps in hospital beds is one component of a mitigation strategy to reduce entrapment. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff answered one resident's call light timely. The resident was observed with their call light on as several staff stood by the nurse's station or walked by the resident's room without answering the call light and/or assisting the resident (Resident #51). Five additional residents complained that it sometimes took staff one to three hours to answer their call lights. (Residents #14, #22, #64, #60 and #16). The census was 75. 1. Review of Resident #51's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/22/21, showed: -admission date of 3/1/21; -Adequate hearing/vision; -Clear speech, distinct intelligible words; -Ability to express ideas and wants: Understood; -Ability to understand others: Understands; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff provided complete privacy for residents by failing to close the room door and pull a privacy curtain for one resident exposed during a skin assessment (Resident #45), and by failing to provide a privacy curtain for another resident a semi-private room (Resident# 224). The census was 75. 1. Review of Resident #45's significant change in status Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/12/21, showed: -admission date of 6/28/04; -Adequate hearing/vision; -Clear speech - distinct intelligible words; -Ability to express ideas and wants: Sometimes understood; -Ability to understand others: Sometimes understands; -Brief Interview for Mental Status (BIMS) score of 03 out of a possible 15 (a score of 0-07 indicates severe cognitive impairment); [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from physical restraints and when restraints were indicated, to document ongoing re-evaluation of the need for restraints for one resident (Resident #59). The sample was 18. The census was 75. Review of the facility's Restraint Alternatives policy, revised 6/3/19, showed: -Protocol: The purpose of the Restraint Alternatives Protocol is to implement individualized interventions for any resident/patient being assessed for or using a physical restraint. The goals of the Restraint Alternatives Protocol are to utilize restraint alternatives instead of or in conjunction with a restraint reduction plan, and optimize dignity and independence; -Procedure: -Review interdisciplinary assessments and documentation; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure allegations of abuse were reported to the Department of Health and Senior Services (DHSS) no later than two hours after an allegation was made by one resident's (Resident #15) family member to facility management, on two separate occasions. The census was 75. Review of the facility's abuse prevention policy dated 2/19, showed: -Prevention and reporting: The administrator has primary responsibility in the facility for implementation of the abuse/neglect program; -The facility will follow all state and federal guidelines on preventing abuse, neglect, mistreatment, exploitation and misappropriation of property. Abuse shall include physical harm, pain, mental anguish, verbal abuse, sexual abuse or involuntary seclusion; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident's (Resident #59) bilevel positive airway pressure machine (BiPap, a machine worn during sleep to maintain consistent breathing) was in working order for use during sleep. In addition, the facility failed to ensure staff documented they notified one resident's (Resident #51) physician for an order to remove the resident's indwelling urinary catheter or why it was necessary to remove the indwelling urinary catheter. The census was 75. 1. Review of Resident #59's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/30/21, showed: -Diagnosis of multiple sclerosis (disease in which the immune system destroys the protective covering of nerves interrupting the nerve signals from the body to the spinal cord/brain); [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor and implement resident-specific interventions, including the provision of nutritional supplements, to maintain acceptable parameters of nutritional status for two residents identified with recent weight loss (Residents #69 and #20.). The sample was 18. The census was 75. 1. Review of Resident #69's medical record, showed -admitted [DATE]; -Diagnoses included heart failure, diabetes with diabetic chronic kidney disease, stroke, attention and concentration deficit following stroke, dysphagia (swallowing disorder) following stroke, vitamin B deficiency, vitamin D deficiency, and depression. Review of the resident's active physician order sheet (POS), showed: -An order, dated 6/4/20, to add ice cream daily at lunch; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident received tube feeding (a tube inserted through the abdomen into the stomach to provide medication, nutrition and hydration) as ordered on a consistent basis. The facility identified two residents with tube feeding, one was sampled and problems were identified (Resident #27). The sample was 18. The census was 75. Review of Resident #27's quarterly Minimum Data Set, a federally mandated assessment instrument completed by facility staff, dated 2/15/21, showed: -admission date of 7/7/17; -Makes Self Understood: Sometimes understood - responds adequately to simple, direct communication only; -Ability to understand others: Sometimes understands - responds adequately to simple, direct communication only; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement an appropriate plan through the facility's Quality Assurance and Performance Improvement (QAPI) committee to correct problems they had identified with pressure ulcer assessments, monitoring and treatments. The census was 75. Review of the facility QAPI Plan, undated, showed: Overall description of QAPI Plan: -The QAPI Plan is based upon person centered care with the goal of providing a home like environment where residents can become more independent. We will develop processes to better enable staff to assist residents in becoming independent and living the best quality life possible. The purpose of the QAPI Plan is to improve Quality of Care and services provided to generate to highest quality of life for our residents; [...]