Blue Springs Wellness & Rehabilitation

Inspectors wroteBased on interview and record review, the facility failed to ensure one sampled resident (Resident #1) out of four sampled residents was treated with dignity and respect. On 7/3/26 Licensed Practical Nurse (LPN) A directed profane language toward the resident while the resident was showering. The facility census was 50 residents. The Administrator was notified on 7/15/26 of the past noncompliance which began on 7/3/26. The facility immediately completed education for Abuse/Neglect/Reporting education and customer service to all staff with 100% pass rate. The resident was assessed for any psychosocial needs. The deficiency was corrected on 7/10/26. Review of the facility's Privacy and Dignity Policy dated 1/26 showed the facility promoted resident care in a manner and an environment that maintained or enhanced dignity and respect in full recognition of each resident's individuality. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to protect two sampled residents (Resident #2 and Resident #3) from abuse. On 7/14/26 Resident #2 hit Resident #3 with a cane and then Resident #3 took the cane and hit Resident #2; resulting in a small red area on Resident #2's right arm and multiple superficial reddened areas and cuts to both Resident #3's arms out of four sampled residents. The facility census was 50 residents. The Administrator was notified on 7/16/26 of the past noncompliance which began on 7/14/26. The facility immediately began education for Abuse/Neglect/Reporting education to all staff persons. The residents were separated and psychiatry followed up with both residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two sampled residents (Resident # 8 and #9), out of 10 sampled residents, were free from abuse when on 8/31/25 Resident #7 pushed Resident #8 out of his/her wheelchair resulting in Resident #8 sustaining a laceration to his/her midforehead; and on 9/2/25 Resident #7 punched Resident #9 in the arm and began pulling on his/her arm causing immediate and residual arm pain and feelings of being attacked. The resident census was 92 residents. On 9/16/25 the Administrator was notified of the past noncompliance which occurred on 8/31/25. The facility had completed interventions for residents and training for all staff prior to state agency investigation. The deficiency was corrected on 9/6/25. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate accounting of narcotics for two sampled residents (Resident #4 and #5) when seven narcotic pain medications were unaccounted for out of 10 sampled residents. The facility census was 92 residents. The Administrator was notified of past noncompliance on 9/16/25 which occurred on 6/17/25. Staff training was completed, and the deficiency was corrected 7/8/25. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a drug regimen review was completed monthly for three sampled residents (Resident #59, #53 and #14) out of 20 sampled residents. The facility census was 84 residents. Review of the facility Drug Regimen Review policy dated June 2020 showed: -The intent was the facility maintained the resident's highest practicable well-being and prevented or minimized adverse (negative or harmful) consequences related to medication. -The pharmacist would review at least once monthly to identify irregularities and any clinically significant risks and/or actual or potential adverse consequences which may result from or be associated with medications. -The Director of Nursing (DON) was responsible for following up with the physician as indicated. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to honor refusal of treatment for one sampled resident (Resident #6) out of 20 sampled residents. The facility census was 84 residents. Review of the facility Resident's Rights Policy dated August 2020 showed treat the decisions of a resident representative as the decision of the resident to the extent required by court or delegated by the resident, in accordance with applicable law. 1. Review of Resident #6's Probate (court division that handles cases involving guardianships) Court order dated 4/18/13 showed: -The resident was determined to be an incapacitated (physically and/or mental unable to make informed, rational judgments and decisions) person. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow manufacturers recommendation and ensure priming (helps ensure that the needle is clear of air bubbles and that the insulin flows freely, guaranteeing you receive the correct dose) Novolog Insulin Flex-Pen (is a pre-filled, disposable insulin pen containing intermediate-acting U-100 isophane insulin human solution) prior to use for one sampled resident (Resident #5) out 20 sampled residents. The facility census was 84 residents. Review of the facility Injectable Medication Administration policy dated September 2018 showed Insulin Pen Devices, dial the dose as instructed by the pen manufacturer. Review of the Novolog Flex Pen manufacturer instruction pamphlet revised February 2023 showed: -Before each injection small amounts of air may collect in the cartridge during normal use. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure physician's orders were complete and contained details for how nursing staff was to check placement of the gastronomy tube (a feeding tube surgically inserted through the abdomen and into the stomach to provide nutrition and medication delivery, or to drain stomach contents), including orders to check residual (the amount of fluid, including formula and gastric secretions, remaining in the stomach after a feeding) prior to adding any fluid to the stomach; failed to ensure handwashing was completed to prevent contamination during care and failed to update the resident's care plan to show the resident no longer received liquid nutrition through the tube for one sampled resident (Resident #14) with tube feeding flushes only out of 20 sampled residents. The facility census was 84 residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to properly store respiratory nebulizer mask/mouthpiece ( medical device used to deliver medication in the form of mist) and tubing when not in use for two sampled residents (Resident #9 and #18) out of 20 sampled residents. The facility census was 84 residents. Review of the facility Oxygen Administration policy dated June 2020 showed all oxygen tubing and masks will be changed weekly and when visibly soiled. 1. Review of Resident #9's admission Record showed the resident had a diagnosis of Chronic Bronchitis (refers to a chronic cough with the production of phlegm resulting from inflammation in the airways). Review of the resident's Quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 3/17/25, showed he/she: [...]

Inspectors wroteBased on interview and record review, the facility failed to identify, assess and provide supportive interventions for one sampled resident (Resident #34), with a diagnosis of Post-Traumatic Stress Disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event), out of 20 sampled residents. The facility census was 84 residents. Review of Trauma-Informed Care Implementation Center (https://www.traumainformedcare.chcs.org/what-is-trauma-informed-care/) copyright 2021 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents with a diagnosis of dementia had a personalized care plan to ensure services to promote the resident's highest level of functioning and psychosocial needs for one sampled resident (Resident #22) out of 20 sampled residents. The facility census was 84 residents. A policy was requested on dementia care planning and the facility failed to provide one. 1. Review of Resident #22's admission Record showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses) in other diseases classified elsewhere, moderate, with mood disturbance. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure the shift change narcotic count was completed and signed by both the on-coming and off-going nursing staff. The facility census was 84 residents. Review of the facility's Storage of Controlled Substances policy revised on September 2018 showed: -Medications classified by the Drug Enforcement Administration (DEA) as controlled substances were subjected to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal, state, and other applicable laws and regulations. -The Director of Nursing (DON), in collaboration with the consultant pharmacist, maintained the facility's compliance with federal and state laws and regulations in the handling of controlled substances. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a drug regimen review (DRR)was completed monthly for one sampled resident (Resident #22), that was on psychotropic medications; failed to complete a gradual dose reduction when needed since the drug regimen review was not performed; and failed to ensure that the resident's psychotropic medication was ordered and used to treat a psychological condition for one sampled resident (Resident #181) out of 20 sampled residents. The facility census was 84 residents. Review of facility policy entitle Drug Regimen Review revised June 2020 showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to label medications with resident's name on the medication container when the box was first opened. The facility census was 84 residents. Review of the facility Medication Storage policy dated September 2018 showed: -The provider pharmacy dispensed medications in containers that met regulatory requirements, included standards set forth by the United States Pharmacopeia (USP). -Medication storage conditions were monitored on a regular basis by the consultant pharmacist and corrective actions were taken if a problem was identified. -The policy did not show where the individual medication container needed to be labeled when the box was labeled. 1. Observation on 3/26/25 at 10:50 A.M. of the 400/500 hall Certified Medication Technician (CMT) medication cart showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to serve pureed (food that has been processed into a smooth, uniform, and pudding-like texture, often by blending, mashing, or straining) food items in the correct texture. This deficient practice had the potential to affect all residents who received pureed diets. The facility census was 84 residents. Review of the Facility Instructions for pureed food items dated 2025, showed: -Any liquid specified in the recipe is a suggested amount of liquid if needed. -Some recipe items will require no liquid added to achieve the desired consistency. -If the product needs thinning, gradually add an appropriate amount of liquid, not water, to achieve a smooth, pudding or soft mashed potato consistency. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure infection control handwashing practice was followed to prevent cross contamination during a gastronomy (which is a surgical opening into the stomach) water flush for one sampled resident (Resident #14); and failed to ensure infection control practices performed hand hygiene between each glove change during care of indwelling Foley Catheter (a urinary bladder catheter inserted through urethra); and failed to ensure to place Personal Protective Equipment (PPE, refers to protective clothing for the eyes, head, ears, hands, respiratory system, body, and feet. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the floors of the following rooms in a clean condition in resident rooms 204, 105, 101, 304, 310, 514, 504, 501, 411, 406, and 407. This practice potentially affected 12 residents. The facility census was 68 residents. 1. Observation on 12/2/24 with the Housekeeping Supervisor showed: - At 12:59 P.M., there was a buildup of cobwebs along the floor and wall area next to the refrigerator in resident room [ROOM NUMBER]. - At 1:01 P.M., there was a buildup of cobwebs in the corners of room [ROOM NUMBER]. - At 1:04 P.M., there was a buildup of dust and debris along the wall in resident room [ROOM NUMBER]. - At 1:05 P.M., there was a buildup of hair and dust along the wall in resident room [ROOM NUMBER]. - At 1:08 P.M., there was a buildup of dust under the bed in resident room [ROOM NUMBER]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff used a gait belt (a device that helps prevent falls) during transfers and ambulation for one sampled resident (Resident #1) out of eight sampled residents. CNA A assisted the resident into the shower room to provide incontinence care. CNA A assisted the resident into a standing position without the use of a gait belt. The resident slid to floor, which resulted in the resident being impaled by his/her wheelchair break lever, causing a penetrating wound (trauma that occurs when a foreign object enters the body) and laceration (a wound produced by the tearing of skin and underlying soft tissue) and was hospitalized for three days. The facility census was 65 residents. The Administrator was notified on 10/1/24 at 12:47 P.M., of the Immediate Jeopardy (IJ) which began on 9/13/24. [...]

Inspectors wroteBased on interview and record review, the facility failed to promote and facilitate one sampled resident's (Resident #3) self determination out of four sampled residents. The facility census was 76 residents. Review of the facility's undated Nursing Home Resident's Rights showed: -The law requires nursing home to promote and protect the rights of resident and stresses individual dignity and self-determination. -Right to dignified existence. --Be treated with consideration, respect, and dignity, recognizing each resident's individuality. --Quality of life is maintained or improved. --Exercise rights without interference, coercion, discrimination, or reprisal. -Right to self-determination. --Reasonable accommodation of needs and preferences. --Participate in developing and implementing a person-centered plan of care that incorporates person and cultural preferences. [...]

Inspectors wrote8. Record review of Resident #48's Face Sheet showed he/she was admitted on [DATE], with diagnoses including failure to thrive, arthritis, pain and vitamin D deficiency. Record review of the resident's quarterly MDS dated [DATE], showed the resident: -Was alert and oriented -Was dependent on staff extensively for bathing, dressing, grooming and toileting. Observation on 7/19/23 at 8:55 A.M., showed the resident was sitting up in his/her specialized wheelchair, dressed for the weather. At this time CNA E and CNA F came into the resident's room and without washing or sanitizing their hands, both CNA's put on gloves. The following occurred: -CNA E and CNA F began to attach the sling to the full body lift. CNA E operated the lift while CNA F monitored the resident and positioned the resident in his/her bed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to have a process to ensure the antibiotic (an antimicrobial [an agent that kills microorganisms or stops their growth] medication) ordered for each resident was appropriate for the treatment of the infection, that excessive antibiotics were not used, and to monitor antibiotic use trends. This had the potential to affect all residents at the facility. The facility census was 77 residents. Review of the facility's policy, dated 3/20/23, titled Assessment of Infections and Antimicrobial Usage showed: -Assessing antimicrobial use was essential for determining antimicrobial trends. -Staff were to perform a monthly review of antibiotics ordered and the clinical documentation for why the medication was ordered. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the main kitchen area free from roaches and to maintain the facility free from numerous flies, which were present throughout the facility. This practice potentially affected all residents. The facility census was 77 residents. 1. Observations on 7/17/23 at 9:27 A.M., showed roaches in the chemical storage room and a roach which crawled on the ceiling over the corridor to back exit door from the kitchen. Observations on 7/20/23, showed: -At 6:51 A.M., showed one roach crawling on wall at the lower level of steam table. -At 7:01 A.M., showed another roach which crawled on the door jamb of door between kitchen and assist dining room. -At 7:05 A.M., one roach crawled on wall next to ice tea making machine. -At 7:07 A.M., four roaches crawled on wall behind ice tea machine. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the ceiling fans in the south dining room free form a buildup of dust; to maintain restroom ceiling vents free of dust inside the vents in resident rooms 401, 507, 308, 306 and 302; to maintain resident use fans free of a heavy buildup of dust in resident room [ROOM NUMBER]; to maintain the ceiling fan in the therapy office free from a heavy buildup of dust; and to maintain the commode seat in the restrooms of 208, 104 and 102. This practice potentially affected at least 50 residents who resided in or used those areas. The facility census was 77 residents. 1. Observation on 7/17/23 at from 12:33 P.M. through 12:52 P.M., showed a heavy buildup of dust on the blades of the ceiling fans over the south dining room where 24 residents ate their lunch meal. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care plans were up to date and reflected the resident's current status for four sampled residents (Resident's #6, #25, #11 and #4) out of 18 sampled residents. The facility census was 77 residents. The facility's policy titled Comprehensive Care Planning dated 7/20/22 showed: -It is the policy to comprehensively assess and periodically re-asses each Resident admitted to the facility. -The results of the resident assessment shall serve as the basis for determining each resident's strengths, needs, goals, life history, and preferences to develop a person centered comprehensive care plan. -Care plans were to include the resident's medical, nursing, physical, mental, and psychological needs. [...]

Inspectors wroteBased on observation interview and record review, the facility failed to ensure physician's orders for oxygen were transcribed to the physician's order sheet for two sampled residents (Resident #179 and #11) and to ensure oxygen equipment such as nasal cannulas (a lightweight tube which on one end splits into two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows), tubing and respiratory suction equipment was stored in a sanitary condition for four sampled residents (Resident #17, #179, #11, and #25) out of 18 sampled residents and seven supplemental residents. The facility census was 77 residents. Review of the facility's Oxygen Storage and Assembly policy and procedure dated 01/2002, showed: -The purpose was to properly store and assemble oxygen tanks and accessories in a safe and correct manner. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure the pharmacist's monthly medication recommendations were addressed in a timely manner for one sampled resident (Resident #25) out of 18 sampled residents. The facility census was 77 residents. Review of the facility's policy, dated 11/28/16, titled Medication Regimen Review (MRR) showed: -Facility staff were to ensure the attending physician, Medical Director, and Director of Nursing (DON) were provided with copies of each residents' MRR. -The attending physician was to document in the resident's chart that the identified irregularity had been reviewed and what, if any action, had been taken. -If the attending physician decided not to make changes per the pharmacist's recommendations, the rationale was to be documented in the resident's chart. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a refrigerator was double locked which had narcotics (controlled substances) stored in it; and to ensure a crash cart (a cart used for medical emergencies) was locked. The facility census was 77 residents. Review of the facility's policy titled Controlled Substances dated [DATE] showed schedule II drugs (drugs with a high potential for abuse, with use potentially leading to severe psychological or physical dependence) were to be kept under two separate locks requiring two separate keys. A policy related to crash carts was requested and not received at time of exit. 1. Observation of the locked unit's medication room on [DATE] at 2:00 P.M. showed: -The medication refrigerator door was unlocked. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure temperatures of hot foods on room tray meals, were maintained at or close to 120 ºF (degrees Fahrenheit) and the facility failed to ensure that seasonings and condiments were available for residents who want to use them. This practice potentially affected five residents on the 200 Hall and at least 12 residents who resided on on the 400 and 500 Hall. The facility census was 77 residents. 1. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the fan vent covers of the freezer free from a dust buildup, to ensure there was not chipping paint on the range hood; to prevent a buildup of dust and grease on the light fixtures over the food preparation area; to maintain the ceiling vents in the south kitchenette and in the main kitchen free of a heavy dust buildup inside the vents; to maintain the outflow vents of the air conditioner free of a heavy dust buildup and to maintain the floor of the south kitchenette free from food crumbs and debris. This practice potentially affected all residents who ate food from the kitchen. The facility census was 77 residents. 1. Observation of the main kitchen on 7/17/23 from 8:58 A.M. through 12:30 P.M., showed: -A buildup of dust on the fan vent covers in the walk-in refrigerator. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the 400 Hall, 500 Hall and 100 Hall shower rooms in good repair to prevent water from flowing into the room adjacent to the 500 Hall shower room; to maintain the following non-resident areas in a sanitary manner: the floor technician's office and under the vending machines; and to maintain the 3 compartment sink in the kitchen in good repair. This practice potentially affected at 50 residents who resided in or used those areas. The facility census was 77 residents. 1. Observation on 7/18/23 at 2:46 P.M., showed a pool of water flowed from the 500 Hall shower room which was the adjoining room to the room (room [ROOM NUMBER]). The water created a standing pool of water around the chairs closest to the 500 Hall shower room. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain adequate ventilation to remove excess heat from the kitchen, and to have ventilation which included negative air flow in the 400 Hall shower room, the 400 Hall medication room, the south hall soiled utility room the 500 Hall shower room, the 300 Hall shower room, the 100 Hall shower room, and the restroom of resident room [ROOM NUMBER] This practice potentially affected 61 residents who resided close to or use those area. The facility census was 77 residents. 1. Observation on 7/17/23 at 11:19 A.M., showed the temperature of the kitchen was 83 ºF (degrees Fahrenheit). During an interview on 7/17/23 at 11:21 A.M., Dietary [NAME] (DC) A said the kitchen felt hot to him/her. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a system was in place for tracking the Certified Nursing Assistant's (CNAs) 12 hours of Continuing Education Units (CEU); and to provide documentation of staff training records and annual dementia care training for 2022 for five sampled staff. The facility census was 77 residents. The facility did not provide a policy related to ongoing staff training by the time of exit. 1. Review of all facility staff in-services attendance sheets showed the following in-services topics were completed from 7/25/22 to 4/25/23: -On 7/25/22 heat safety and signing Medication Administration Records (MAR)/Treatment Administration Record (TAR). -On 10/25/22, fire drills are serious. -On 11/10/22, safe resident handling. -On 11/25/22, abuse. -On 2/25/23, resident rights and use of mechanical lifts. -On 3/7/23, door alarms. [...]

Inspectors wroteBased on observation, interview, and record review, showed the facility failed to ensure the dignity of one sampled resident (Resident #17) was protected by failing to ensure the resident's catheter (tube known as a urinary catheter is inserted into the bladder through the urethra to allow urine to drain from the bladder for collection) bag was in a privacy bag out of 18 sampled residents. The facility census was 77 residents. 1. Review of the Resident #17's Face Sheet showed he/she was admitted on [DATE], with diagnoses including spinabifida (a birth defect in which a developing baby's spinal cord fails to develop properly), high blood pressure and neurogenic bladder (to lack bladder control due to a brain, spinal cord or nerve problem). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a transfer notice was sent to the Ombudsman (individuals who help residents in long-term care facilities maintain and improve their quality of life by helping ensure their rights are preserved and respected) when one sampled resident (Resident #36) was transferred to the hospital out of 18 sampled residents. The facility census was 55 residents. A facility policy related to Ombudsman notification was requested and not received at the time of exit. 1. Review of Resident #36's face sheet showed he/she re-admitted to the facility on [DATE] with the following diagnoses: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident and/or responsible party were informed of and signed a bed hold for two sampled residents (Resident #16 and Resident #36) out of 18 sampled residents. The facility census was 77 residents. Review of the facility's Bed Hold policy and procedure dated showed: -Upon leaving the facility for admission to a hospital or for therapeutic leave, a resident shall be guaranteed a bed in this facility upon return if the resident's condition is such that he/she is appropriate for the level of care provided by the facility and a Medicaid eligible resident was not in the hospital or on leave for more than 10 consecutive days; [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure a Quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) was accurate and submitted on time for one sampled resident (Resident #25) out of 18 sampled residents. The facility census was 77 residents. Review of the facility's policy, dated 11/1/17, titled Comprehensive Assessments/MDS showed: -Staff were to complete a Quarterly MDS on each resident within 92 days of the previous MDS. -Staff were responsible for ensuring the MDS was accurate. 1. Review of Resident #25's face sheet showed he/she was admitted on [DATE] with a diagnoses of acute (short term) and chronic (long term) respiratory failure (a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide). Review of the resident's MDS submissions showed: [...]

Inspectors wroteBased on observation interview and record review, the facility failed to ensure baths were given and documented twice weekly for one sampled resident (Resident #34) and to provide one sampled resident (Resident #4) proper Activities of Daily Living (ADL) care necessary to maintain grooming needs out of 18 sampled residents. The facility census was 77 residents. A policy on ADL care was requested and not received at the time of exit. 1. Review of Resident #34's Face Sheet showed he/she was admitted on [DATE], with diagnoses including spondylosis (arthritis of the spine), Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), history of stroke, diabetes, high blood pressure, history of falls and abnormal gait (balance). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure to complete and document a comprehensive Weekly Skin Assessment for two sampled residents (Resident #62 and Resident #64) who were high risk and had current treatments for skin breakdown, out of 18 sampled residents. The facility resident census of 77 residents. Review of the facility Policy and Procedure Skin Condition Monitoring revised 3/16/23 showed: -Licensed nursing staff were responsible for providing monitoring, treatment and documentation of any resident with skin abnormalities. -Documentation of the skin abnormality must occur upon identification and at least weekly thereafter until the area were healed. The documentation must include the following: size, shape, depth, odor, color and condition of the tissue. -Treatment and response to treatment. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe secure storage of cleaning chemicals by leaving the housekeeping keys unsupervised in the door located on memory care unit for over 30 minutes. The facility census was 77 residents. A policy for storage of housekeeping chemical cleaning supplies was requested and not received at the time of exit. 1. Review of Resident #53's Quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 2/18/23 showed: -The resident was severely cognitively impaired. -He/she had wandering behaviors. Observation on 7/19/23 at 11:00 A.M. showed the resident was walking up and down the hallway with his/her head down and would enter the conference room when the door was open. 2. Observation on 7/19/23 at 11:45 A.M. to 12:12 P.M. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the resident's catheter (a tube is inserted into the bladder through the urethra to allow urine to drain from the bladder for collection) below the bladder for two sampled residents (Resident #17 and #11) with a history of urinary tract infections (UTI - an infection of one or more structures in the urinary system); failed to provide catheter care as ordered by the resident's physician and to prevent the catheter drainage bag from coming in contact with the floor without a barrier for one sampled resident (Resident #11) out of 18 sampled residents. The facility census was 77 residents. Review of the resident's Catheter Care policy and procedure dated 3/15/23, showed catheter care is provided daily and as needed to all residents who have an indwelling catheter to reduce the incidence of infection. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure ongoing communication of dietary needs related to assistance while eating; to update the dietary cards; and to include the assistance needed for eating within the care plan for two sampled residents (Resident #36 and Resident #53) out of 18 sampled residents. The facility census was 77 residents. 1. Review of Resident #36's face sheet showed he/she admitted to the facility with the following diagnoses: -Unspecified Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses) unspecified severity with behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure pneumococcal (a name for any infection caused by bacteria called Streptococcus pneumonia) vaccinations were offered for four sampled residents (Resident #64, #179, #25, and #26) out of 18 sampled residents. The facility census was 77 residents. Review of the facility's policy, dated 1/23/20, titled Immunization of Residents showed: -Staff were to offer all residents vaccinations to aid in the prevention of infectious diseases. -Staff were to obtain proof of pneumococcal vaccinations upon admission. -Staff were to offer the pneumococcal vaccine within 30 days of admission. -Staff were to document all vaccinations on the Immunization Record. 1. Review of Resident #64's admission Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning), dated 5/27/22 showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain a comprehensive, facility-specific infection prevention and control program designed to help prevent the development and transmission of waterborne pathogens (a bacterium, virus, or other microorganism that can cause disease), which included the following: a risk assessment to identify where waterborne pathogens could grow and spread, diagrams of which hot water heaters provide hot water to which sections of the facility, testing protocols with acceptable ranges for control measures when control measures in water from the water company were not maintained, how the facility will account for changes in water quality such as water main breaks and construction, and specific actions that would be taken in response to a legionella positive water sample. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify three sampled residents (Residents #61, #50 and #52) who had amounts in their resident trust which exceeded the $4,835.00, which is within $200 of the limit of $5,035.00 limit for required notification to residents to spend down. This practice affected three residents. The facility census was 67 residents. 1. Record review of Resident #61's trust fund yearly statement dated 1/1/22 through 3/31/22, showed the resident had the following balances: -A balance of $9,240.42 on 1/31/22. -A balance of $9,292.56 on 2/28/22. -A balance of $9,342.56 on 3/31/22. 2. Record review of Resident #50's trust fund yearly statement dated 1/1/22 through 3/31/22, showed the resident had the following balances: -A balance of $5,421.39 on 2/28/22. -A balance of $6,987.36 on 3/31/22. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain a surety bond (a promise to be liable for the debt, default, or failure of another; It is a three-party contract by which one party (the surety or bond company) guarantees the performance or obligations of a second party (the principal (the nursing home) to a third party (the oblige--the residents who are a part of the resident trust)) that was one and one half times the average of the monthly balance of the reconciled bank statements for the resident trust. This practice potentially affected 14 residents who allowed the facility to manage their resident funds. The facility census was 67 residents. 1. Record review of the instructions for determining what a surety bond amount should be, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) for two sampled residents (Resident #1 and #61) and one supplemental resident (Resident #267) and failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) for two sampled resident (Resident #1 and #61) who remained in the facility but were discharged from Medicare part A services out of three residents sampled for beneficiary notices. The facility census was 67 residents. The facility did not have a policy regarding SNF ABNs or NOMNCs. Record review of the undated Form Instructions for the NOMNC (Centers for Medicare and Medicaid Services Survey and Certification (CMS)-10123 showed the NOMNC must be delivered at least two calendar days before Medicare coverage services end. Record review of the CMS memo (S&C-09-20), dated 1/9/09, showed: [...]

Inspectors wroteBased on observation and interview ,the facility failed to maintain the mattresses in resident rooms [ROOM NUMBERS] in an easily cleanable condition; to maintain three ceiling fans in the Special Care Unit (SCU) free of a buildup of dust; to maintain the base of two stand-up lifts without cracks; to maintain the ceiling vents in the 300 hall shower room and the restrooms of resident rooms 306, 302, 212, 203, 201, 109, 108, 105, 103, and the north dining room, free of a heavy buildup of dust inside the vents; to maintain the commode seats in the restrooms of resident rooms [ROOM NUMBERS] in an easily cleanable condition; and to maintain the base of two stand-up lifts without cracks. This practice potentially affected at least 40 residents who resided in or used those areas or equipment throughout the facility. The facility census was 67 residents. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to assess a resident using the quarterly review instrument specified by the State and approved by Centers for Medicare and Medicaid Services (CMS) not less frequently than once every 3 months for nine sampled residents (Resident #31, #9, #34, #32, #27, #47, #45, #7, and #26) out of 17 sampled residents. The facility census was 67 residents. Record review of the facility policy titled Comprehensive Assessment/MDS (MDS - a federally mandated assessment instrument completed by facility staff for care planning) revised 11/1/2017 showed: -The facility would comprehensively asses and periodically reassess each resident admitted to the facility. -The MDS would be re-evaluated quarterly-within 92 days of previous MDS. [...]

Inspectors wroteBased on interview and record review,the facility failed to electronically transmit within 14 days of completion 46 out of 100 Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) assessment and tracking records (entry/discharge records) electronically transmitted from 1/7/22 through 3/8/22. The facility census was 67 residents. Record review of the facility Comprehensive Assessment/MDS policy, revised 11/1/20217 showed: The MDS would be transmitted to the Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system as required by Federal Regulation and designated in the Resident Assessment Instrument (RAI) Manual. Record review of the Long Term Care Facility RAI 3.0 User's Manual, Version 1.17.1, dated October 2019 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to develop individualized care plans describing a need or problem and indicating approaches/interventions to assist the resident in relation to the need or problem for two sampled residents (Resident #29 and #41) and to complete a comprehensive care plan addressing all resident needs within 21 days of admission for one sampled resident (Resident #265) out of 17 sampled residents. The facility census was 67 residents. Record review of the facility's Comprehensive Care Planning policy, revised 11/1/17 showed: -The facility will comprehensively assess and periodically reassess each resident admitted to the facility. [...]

Inspectors wroteBased on observation and interview, the facility failed to post required nurse staffing information, which included the total and actual hours worked by both licensed and unlicensed staff directly responsible for resident care, per shift on a daily basis and visible for residents, visitors, and staff to view. The facility census was 67 residents. A policy was requested but not received by the facility. 1. Observation on 3/31/22 at 11:36 A.M. showed: -The front lobby area, the front nurses station and area by the administrators office. -There was no staffing posted. Observation on 4/1/22 at 10:58 A.M. showed: -The front lobby area, the front nurses station and area by the administrators office. -There was no staffing posted. Observation on 4/4/22 at 5:40 A.M. showed: -The front lobby area, the front nurses station and area by the administrators office. -There was no staffing posted. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare pureed (food that is prepared into a paste or thick liquid suspension usually made from cooked food that was finely ground) eggs in a manner according to the recipe to be flavorful. This practice potentially affected three residents who had physician's orders for pureed diets. The facility also failed to maintain food on breakfast trays delivered to the Special Care Unit (SCU) at or close to 120 ºF (degrees Fahrenheit) of at least seven residents who were served later in the process of serving. The facility census was 67 residents. 1. Record review of the undated recipe for six servings of pureed eggs, showed: - Six 2 ounce (oz.) servings of scrambled eggs. - 6 fluid oz. of milk. - 1 .5 Tablespoons of food thickener (starch or gel-based additives that make fluids and edibles easier to swallow). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to do or maintain the following: keep the package of bacon in the walk-in fridge covered; maintain the floor of the walk-in fridge free of a buildup of dust and food debris; maintain proper illumination from the light fixtures over the dishwasher area; maintain the top inner part of the ice-machine free of a pink colored slime; maintain the light fixtures in the kitchen free of grease and dust; label a container with the name of what is in the container; and maintain the cutting boards in an easily cleanable condition. This practice potentially affected 65 residents who ate food from the kitchen. The facility census was 67 residents. 1. Observations during the initial kitchen tour on 3/31/22 from 8:56 A.M. through 9:13 A.M., showed: - Uncovered bacon in the walk-in refrigerator. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to label and date food that was brought in from outside sources for residents who resided on the Special Care Unit (SCU) and the Front Halls. This practice potentially affected at least six residents who resided in those areas. The facility census was 67 residents. Record review of the facility's policy entitled Food from Outside Sources/Personal Food Storage, revised on 6/09, 10/14 and 4/17, showed: - It is the policy of facility to obtain food for resident consumption from sources approved or considered satisfactory by Federal, State or local authorities. - All resident have the right to accept food brought to the facility by any visitor(s) and/or food from a facility garden, however the food must be handled in a way to ensure resident safety. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the dumpster lids was closed on two different days of the survey. This practice potentially affected the outdoor premises of the facility with the potential of pest harborage. The facility census was 67 residents. 1. Observations on 4/1/22 at 9:53 A.M., 10:22 A.M., 11:58 A.M., and 1:08 P.M., showed the lid to one of the outdoor dumpster's open and not closed. Observations on 4/4/22 at 9:08 A.M., 11:03 A.M., 1:12 P.M., 2:13 P.M., and 3:39 P.M., showed the lid to one of the outdoor dumpster open. During an interview on 4/4/22 at 2:15 the Assistant Dietary Manager said he/she expected all facility staff to close the lid after dumping trash into the dumpster. Record review of the 2009 Food and Drug Administration (FDA) Food Code Chapter 5-501.110 entitled Storing Refuse, Recyclables, and Returnable's, showed: [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the audible (heard or capable of being heard) function of the call lights from the following areas: Resident room [ROOM NUMBER], the 400 Hall shower room and the 500 Hall shower room. This practice potentially affected 26 residents who resided on those halls. The facility census was 67 residents. 1. Observation and interview on 4/4/22 at 11:18 A.M., showed: - The call light string in the 500 Hall shower room was activated. - Certified Nurse's Assistants (CNAs) E and G were at the nurse's station. - CNAs E and G both said the call light from the 500 Hall shower room was not audible at the nurse's station. 2. Observation and interview on 4/4/22 at 11:24 A.M., showed: - The call light string in the 400 Hall shower room was activated. [...]

Inspectors wroteBased on observation and interview, the facility failed to do the following: repair a 13 inch (in.) long by ¼ in. gap between a climate control unit and the wall where it was installed on resident room [ROOM NUMBER]; maintain the covebase (a type of trim that is installed along the base of an interior wall where the wall meets the floor which is used to protect the base of a wall from damage and to provide a finished look) area in good repair in resident room [ROOM NUMBER] and 301; failed to maintain the tiles in good repair, which exposed the metal studs underneath the layer of tile on the 300 Hall shower room; maintain the ceiling vent in resident room [ROOM NUMBER] in operable condition because the knob to open the vent was absent; maintain the paint on the ceiling of resident room [ROOM NUMBER] in good condition; maintain the ceiling of the kitchen in good repair; [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent a negative balance for one discharged resident (Resident #266) who was discharged on 3/26/21 and to address that negative balance until 4/5/22. This practice potentially affected 14 residents who allowed the facility manage their resident funds. The facility census was 67 residents. 1. Record review of the Trust Fund Yearly Detail Register showed: -Resident #266's family received $669.01, after the resident was discharged on 3/26/21, instead of $372.01, because $297.00 was spent on an insurance plan on 3/3/21 and not deducted from the resident's ledger. -Leaving a negative balance of $297.00 outstanding on the resident's account. [...]

Inspectors wroteBased on interview and record review, the facility failed to have advanced directives (documents that allow one to communicate their health care preferences when decision-making capacity is lost) and/or a Durable power of Attorney (DPOA- a person previously identified to make decisions for an individual in the event of inability to make wishes known) for one sampled resident (Resident #265) who had an Outside the Hospital Do Not Resuscitate (DNR - an order from a doctor that resuscitation should not be attempted if a person suffers cardiac or respiratory arrest) form signed by a family member; and to ensure physician's orders for a code status change were obtained when OHDNR forms were signed for two sampled residents (Resident #265 and Resident #7) out of 17 sampled residents. The facility census was 67 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an annual comprehensive assessment was completed for one sampled resident (Resident #47) and to complete a comprehensive admission assessment for one sampled resident (Resident #265) out of of 17 sampled residents. The facility census was 67 residents. Record review of the Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.1, October 2019 showed: -The Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff for care planning) is one of the three components of the RAI process. -The MDS is a core set of screening, clinical, and functional status elements, including common definitions and coding categories, which forms the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the resident and/or their representative with a summary of a baseline care plan that was developed within the first 48 hours of admission for one sampled resident (Residents #265) out of 17 sampled residents. The facility census was 67 residents. Record review of the facility's Baseline Care Planning policy revised 3/16/22 showed: -The baseline care plan would seek to develop a personal plan of care. -The baseline care plan should be completed within 48 hours. -The baseline care plan should be reviewed with the resident and a copy should be provided to the resident and the resident's designated representative. 1. Record review of Resident #265's admission nurses note dated 2/9/22 showed: -The resident was admitted to the facility via transport van. [...]

Inspectors wroteBased on interview and record review, the facility failed to the extent practicable, to include residents and their representatives in the care planning process and failed to conduct care plan conferences to include resident/resident representative participation for two sampled residents (Residents #26 and #57) out of 17 sampled residents. The facility census was 67 residents. Record review of the facility's Comprehensive Care Planning policy revised 11/1/17 showed: -The Interdisciplinary team and other staff needed as appropriate should meet to discuss resident care services and needs. -The resident and/or the resident's representative should participate as possible/appropriate. -The comprehensive care plan should strive to be person centered. 1. Record review of #26's Profile Face Sheet showed he/she: -Was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure arrangements were made to replace broken and scratched glasses for one sampled resident (Resident #41) out of 17 sampled residents. The facility census was 67 residents. 1. Record review of Resident #41's Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE]. Record review of the resident's Social Services notes dated November 2020 to December 2020 showed no Social Service notes mentioning the resident's vision needs. Record review of the facility's Tentative Optometrist List (a list of residents needing to see the optometrist), dated 11/30/21 showed: -The resident was on the list of residents scheduled to see the optometrist on 12/14/21. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure smoking assessments were completed on a quarterly bases to ensure one sampled resident (Resident #20) was able to smoke safely, out of 17 sampled residents. The facility census was 67 residents. Record review of the facility's undated Smoking Policy showed: -Smoking would be permitted by staff and residents in an approved outside location. -Residents must always be accompanied by a staff member to smoke and may not keep their own smoking materials. -Note: There was no mention of a resident assessment for ability to smoke safely or to determine what modifications may need to be considered to modify independent smoking so that resident safety was maintained. Record review of the facility's undated Smoking Assessment form showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assess placement of a percutaneous endoscopic gastrostomy tube (PEG tube - a tube that is placed into a patient's stomach as a means of feeding them when they are unable to eat) using the current standard of practice and to have a policy in place reflecting the standard of practice for one sampled resident (Resident #31) out of 17 sampled residents. The facility census was 67 residents. Record review of the facility policy titled Enteral Feedings revised 2/08 showed: -Placement of tube will be confirmed via aspiration. -If unable to confirm placement via aspiration, air instillation (auscultation) method may be used. -Placement will be confirmed prior to giving medications. -Note: The policy did not reflect the current standard of practice for assessing PEG tube placement. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary oversight and intervention; and failed to care plan, fully assess, and thoroughly document the behavioral needs of one sampled resident (Resident #29) who had a known behavior of targeting certain residents and pinching and scratching them. Additionally, the facility failed to fully assess the impact of the resident's behavior on other residents by not comprehensively assessing and documenting injuries (bruises and scratches) that were sustained from the pinching and scratching for one sampled resident (Resident #61) out of 17 sampled residents. The facility census was 67 residents. Record review of the facility's Behavior Record Guide, Informational dated 9/1/19 showed: [...]