Bluebird Wellness and Rehabilitation

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders and facility policy when anti-anxiety medications were not administered as ordered for one resident (Resident #4). The sample was 8. The census was 151. Review of the facility's undated Medication - Administration policy showed:-Purpose: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff provided adequate supervision and assistance to prevent accidents for one resident (Resident #2) when one staff repositioned the resident, who had a diagnosis of quadriplegia (loss or partial loss of movement and sensation in all four limbs) onto their side and left the resident unattended to obtain supplies. When the staff member returned to the room, the resident was on the floor. The sample was 16. The census was 158. The administrator was notified on 10/9/25 at 6:30 P.M., of past noncompliance which began on 8/9/25. Once the nurse was made aware of the incident, he/she assessed the resident, completed a skin and pain assessment, administered pain medication, started neurological checks, and notified the Medical Doctor (MD). The resident complained of pain and requested to go to the hospital. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's were free from accident hazards during resident smoking and in the smoking areas. The smoking area showed evidence of unsafe smoking practices such as trash in the ash bins and cigarette butts on the ground. Residents who smoke were not accurately and completely assessed for their ability to smoke safely. In addition, the facility did not follow their smoking policy as it relates to assessment, supervision, and securing smoking materials for three of four residents investigated for safe smoking practices (Residents #94, #4, and #16). The census was 165. The sample was 33. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored appropriately. The facility identified seven medication/treatment carts and two medication rooms. Four of the seven carts and both medication rooms were checked for medication storage. Issues were found in all four medication carts. Staff failed to discard expired bottles of over the counter (OTC) medications, and a bottle of Pro-Stat protein drink (increases wound healing). In addition, the staff failed to refrigerate a bottle of Latanoprost eye drops (treats glaucoma, an eye condition that causes blindness), a bottle of Lorazepam (used to treat anxiety), and a vial of tuberculin purified protein derivative (PPD, used to diagnose silent (latent) tuberculosis (TB) infection) solution. Furthermore, the staff failed to label one insulin pen with a resident's name. [...]

Inspectors wroteBased on interview and record review, the facility failed to honor one resident's Durable Power of Attorney (DPOA, a legal document that allows a person to appoint another person to manage their financial and/or healthcare matters) to act on their behalf on financial matters (Resident #174). The facility failed get signed authorization from the resident's DPOA to open a resident trust account and to have his/her Social Security directly deposited into the resident trust account. In addition, the facility failed to notify the resident and his/her DPOA of a debited care cost at the time the resident was discharged from the facility. The census was 165. Review of Resident #174's face sheet, showed:-admitted on [DATE];-discharged on 7/11/25. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure recommendations from a Level two Pre-admission Screening and Resident Review (PASARR) were incorporated into the plan of care for 1 of 3 residents reviewed for PASARR (Resident #119). This failure had the potential to negatively affect the resident's mental and psychosocial well-being. The census was 165. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services per professional standards for one resident who had an order for daily wound care and the treatment was not completed over the weekend (Resident #26). Staff failed to ensure one resident's treatment was applied as needed for a cancer lesion with drainage that was not covered and exposed (Resident #130). In addition, staff failed to obtain weights on one resident per their policy. When the weight was obtained, the resident had experienced a weight loss (Resident #1). The census was 165. The sample was 33. Review of the facility's Wound Management policy dated June 2020, showed:-Purpose: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and care in accordance with acceptable standards of practice, for one resident who had a fall. Staff failed to follow their fall policy and failed to document the circumstances of the fall, assessment of the resident, and/or complete neurological checks on the shift that the fall occurred. In addition, the staff present at the time of the fall failed to report the fall to the physician or the oncoming shift. During the next shift, approximately 8 hours after the fall, the resident was found with significant facial bruising of unknown origin that was only determined to be a fall after interview with the resident and the resident's roommate (Resident #22). The census was 165. The sample was 33. Review of the facility's undated Fall Management Program policy, showed:-Purpose: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy for dialysis (a procedure that cleanses the blood of its impurities) when staff failed to document pre/post dialysis assessments. The facility identified five residents who received dialysis services. Two residents were sampled, and issues was found with one (Resident #150). The sample was 33. The census was 165. Review of the facility's Dialysis Care Policy, revised 6/20, showed:-Policy: [...]

Inspectors wroteBased on interview and record review, the facility failed to implement their policy and procedure for the monthly drug regimen review by failing to ensure the physician or designee responded to the pharmacy recommendation timely for two of five residents sampled for medication review (Residents #3 and #145). The sample was 33. The census was 165. Review of the facility's Documentation and Communication of Consultant Pharmacist Recommendations Policy, dated 8/20, showed:-Policy: The consultant pharmacist works with the facility to establish a system whereby the consultant pharmacist observations and recommendations regarding residents' medication therapies are communicated to those with authority and/or responsibility to implement the recommendations and are responded to in an appropriate and timely fashion;-Recommendations: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure reach resident relieves food choices that accommodate their preferences, for one resident (Resident #171) who preferred chocolate milk with all meals and was not provided with chocolate milk. The census was 165. The sample was 33. Review of the Know Your Rights, resident rights poster, located at the nurse stations, showed residents have the right to participate in their care. Review of Resident #171's medical record, showed:-Diagnoses included: Dysphagia (difficulty swallowing) after a stroke and diabetes;-A nutritional communication form, dated 7/29/25, showed meal location preference: In room. Moderately thick liquids. During an interview on 8/4/25 at 9:18 A.M., the resident said he/she has not had breakfast yet. When he/she gets his/her breakfast he/she wants chocolate milk. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide services per acceptable standards of practice for one resident (Resident #8) when a Certified Medication Technician (CMT) administered a medication without a physician's order. The sample size was 8. The census was 174. Review of the facility's Medication Administration policy, undated, showed: -Purpose: To provide practice standards for safe administration of medications for residents in the facility; -Policy: Medication will be administered by a licensed nurse per the order of the attending physician or licensed independent practitioner, or as consistent with state law; -Procedure: Compare the licensed practitioner's prescription/order with the medication administration record (MAR); -Compare the licensed practitioner's order with the pharmacy label on the medication package; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide or obtain laboratory services to meet the needs of residents for one of eight sampled residents (Resident #2). The census was 174. Review of the facility's Refusal of Treatment policy, revised 8/2020, showed: -Purpose: To ensure that residents are able to exercise their right to refuse treatment; -Policy: Facility will honor a resident's request not to receive medical treatment as prescribed by his/her attending physician, as well as care services outlined on the resident's assessment and care plan. treatment is defined as care provided for purposes of maintaining/restoring health, improving functional level, or relieving symptoms; -Procedure: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff used acceptable infection control procedures during blood sugar testing and insulin administration for one sampled resident (Residents #5). The census was 174. Review of the facility's Handwashing/Hand Hygiene policy, revised August 2019, showed: -Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections; -Policy Interpretation and Implementation: All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections; -All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors; [...]

Inspectors wroteSee Event ID 56TT13. This deficiency is uncorrected. For previous examples, refer to the Statement of Deficiencies dated 7/12/24. Based on observation, interview and record review, the facility failed to ensure staff followed facility policies by failing to ensure nurses assessed and notified the physician of Resident #29's right buttock/right ischium (lower and back part of the hip bone) when Certified Nursing Assistants (CNAs) alerted the nurses of issues for the resident's skin and documented open areas on bath sheets. The resident also requested the facility's former Wound Nurse (WN) assess his/her bottom, but she refused. The resident's request was witnessed by CNA N. [...]

Inspectors wroteSee Event ID 56TT13. Based on observation, interview, and record review, the facility failed to follow their policies by failing to promptly assess one resident's right hip wound after a Certified Nursing Assistant (CNA) reported the wound to a Licensed Practical Nurse (LPN) the day before it was assessed and a treatment had been started (Resident #36). Another resident said he/she had reported his/her bottom was sore to staff and no one assessed his/her bottom until two days later when a wound was identified (Resident #39). Both residents complained the facility's largest incontinent briefs were too small and caused the wounds. In addition, staff failed to promptly assess and treat one resident with a right palm laceration. After waiting approximately one hour for staff to treat the laceration, the resident returned to his/her room without receiving treatment (Resident #3). [...]

Inspectors wroteSee Event ID 56TT13. Based on interview and record review, the facility failed to provide appropriate nursing assessments per facility policy for residents with a tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck), diagnosed with respiratory infection and vomiting. The facility identified seven residents with tracheostomy, three were sampled and failures were found with two (Resident #6 and #44). The census was 156.

Inspectors wroteSee Event ID 56TT13. Based on observation, interview and record review, the facility failed to ensure a sufficient number of skilled licensed nurses were on duty each shift to provide nursing care to all residents in accordance with resident care plans and per the facility assessment. The facility failed to ensure a licensed nurse was on duty each shift, for the rehab building. This resulted in four residents (Residents #16, #44, #6, and #45) not receiving tube feedings (enteral nutrition, used to give medicines and liquids, including liquid nutrition, through a small tube placed through abdomen into the stomach) and not receiving medication as ordered. Three residents (Residents #16, #44, and #6) did not receive tracheostomy (trach, a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck) care. The sample was 28. [...]

Inspectors wroteSee Event ID 56TT13. Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice when staff failed to ensure one resident wore a compression suit (applied to reduce edema (swelling) and increase circulation) on the lower extremities every night for one hour (Resident #28). In addition, staff failed to ensure one resident received a glucose monitoring device as ordered (Resident #6). The sample size was 28. The census was 156.

Inspectors wroteSee Event ID 56TT13. Based on interview and record review, the facility failed to ensure residents were free from significant medication errors. Staff failed to administer seizure medication for three residents (Residents #45, #6, and #16). Staff failed to administer two antibiotics to one resident (Resident #6). Staff failed to administer an anticoagulant (medication used to prevent blood clots) to one resident (Resident #45). The facility staff failed to notify the physician and resident representative (RR) of the medication errors. This failure put the residents at risk for significant medication errors that go unreported to the physician, resulting in potential for compilations related to missed doses. The sample was 28. The census was 156.

Inspectors wroteSee Event ID 56TT13. This deficiency is uncorrected. For previous examples, refer to the Statement of Deficiencies dated 6/18/24 and 7/12/24. Based on interview and record review, the facility failed to maintain complete and accurate resident records and follow their policy for resident change in condition. On 8/4/24, one resident had a change in condition and went to the hospital where he/she was admitted . The resident's electronic health record (EHR) showed no documentation on 8/4/24, regarding the resident's change in condition, physician notification, and/or the time the resident eventually went to the hospital (Resident #29). In addition, the facility failed to ensure two residents' electronic Medication Administration Record (eMAR) and electronic Treatment Administration Record (eTAR) were completed per facility policies and procedures. [...]

Inspectors wroteSee Event ID 56TT12. Based on observation, interview, and record review, the facility failed to ensure treatments were completed as ordered by the physician for three residents (Resident #19, #21, and #22). Facility nursing staff documented the treatments as completed, although they were not completed. The facility identified 15 residents with pressure ulcers. Four were sampled and problems were found with three. The census was 164.

Inspectors wroteSee Event ID 56TT12. This deficiency is uncorrected. For previous examples, refer to the Statement of Deficiencies dated 6/18/24. Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 25 opportunities for errors, two errors occurred, resulting in an 8.0% medication error rate (Residents #15). The census was 164.

Inspectors wroteSee Event ID 56TT12. This deficiency is uncorrected. For previous examples, refer to the Statement of Deficiencies dated 6/18/24. Based on observation, interview and record review, the facility failed to ensure staff accurately documented on the treatment administration record (TAR) when pressure ulcer (localized damage to the skin caused by prolonged pressure) treatments were not completed as ordered for three residents (Residents #19, #21 and #22). In addition, one resident (Resident #15) requested and received pain medication without staff documenting the medication was given, including where the resident's pain was located, and the intensity of the resident's pain. The census was 164.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure treatments were completed as ordered by the physician for three residents (Resident #19, #21, and #22). Facility nursing staff documented the treatments as completed, although they were not completed. The facility identified 15 residents with pressure ulcers. Four were sampled and problems were found with three. The census was 164. Review of the facility's undated Skin Care & Wound Management Overview policy and procedure, included the following: -Definitions: Pressure ulcer is defined as a localized injury to skin and/or underlying tissue usually over a bony prominence, as a result of pressure in combination with shear and/or friction; -Policy: -The facility staff strives to prevent resident skin impairment and to promote the healing of existing wounds. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policies by failing to promptly assess one resident's right hip wound after a Certified Nursing Assistant (CNA) reported the wound to a Licensed Practical Nurse (LPN) the day before it was assessed and a treatment had been started (Resident #36). Another resident said he/she had reported his/her bottom was sore to staff and no one assessed his/her bottom until two days later when a wound was identified (Resident #39). Both residents complained the facility's largest incontinent briefs were too small and caused the wounds. In addition, staff failed to promptly assess and treat one resident with a right palm laceration. After waiting approximately one hour for staff to treat the laceration, the resident returned to his/her room without receiving treatment (Resident #3). The census was 156. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate nursing assessments per facility policy for residents with a tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck), diagnosed with respiratory infection and vomiting. The facility identified seven residents with tracheostomy, three were sampled and failures were found with two (Resident #6 and #44). The census was 156. Review of the facility's Tracheostomy (Trach) Care policy, dated 6/2020, showed: -Tracheostomy care will be performed as ordered by the Attending Physician. -Licensed Nurses or a Respiratory Therapist (RT) may perform tracheostomy care. -Report any unusual observations to the Attending Physician immediately. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a sufficient number of skilled licensed nurses were on duty each shift to provide nursing care to all residents in accordance with resident care plans and per the facility assessment. The facility failed to ensure a licensed nurse was on duty each shift, for the rehab building. This resulted in four residents (Residents #16, #44, #6, and #45) not receiving tube feedings (enteral nutrition, used to give medicines and liquids, including liquid nutrition, through a small tube placed through abdomen into the stomach) and not receiving medication as ordered. Three residents (Residents #16, #44, and #6) did not receive tracheostomy (trach, a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck) care. The sample was 28. The census was 156. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 43 opportunities for errors, seven errors occurred, resulting in an 16.28% medication error rate (Residents #11, #3, #8, #10 and #9). The medication pass sample size was five, and problems were found with all five. The census was 157. Review of the facility's Physician Orders policy, undated, included the following: -Policy: It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. The safety of residents, staff and visitors is of primary importance. The purpose of this policy is to provide guidance for licensed nurses and licensed therapist to accurately document physician and provider orders as determined by the licensee's Scope of Practice; -Procedure: I. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff did not document medications as provided on the medication administration record when the medications were not actually provided. Staff failed to document why the medications were not provided for 5 of 6 sampled residents that were observed for a medication administration pass (Residents #11, #3, #8, #9, #10). The census was 157. Review of the facility Physician Orders policy, undated, included the following: -Policy: It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. The safety of residents, staff and visitors is of primary importance. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice when staff failed to ensure one resident wore a compression suit (applied to reduce edema (swelling) and increase circulation) on the lower extremities every night for one hour (Resident #28). In addition, staff failed to ensure one resident received a glucose monitoring device as ordered (Resident #6). The sample size was 28. The census was 156. 1. Review of Resident #28's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/24/24, showed: -Adequate hearing; -Makes Self Understood: Understood; -Ability To Understand Others: Understands - clear comprehension; -Moderately impaired cognition; -Rejection of Care: Behavior not exhibited; -Diagnosis of high blood pressure. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from significant medication errors. Staff failed to administer seizure medication for three residents (Residents #45, #6, and #16). Staff failed to administer two antibiotics to one resident (Resident #6). Staff failed to administer an anticoagulant (medication used to prevent blood clots) to one resident (Resident #45). The facility staff failed to notify the physician and resident representative (RR) of the medication errors. This failure put the residents at risk for significant medication errors that go unreported to the physician, resulting in potential for compilations related to missed doses. The sample was 28. The census was 156. 1. Review of the facility's Facility Assessment Tool, last reviewed on 8/2/24, showed: -Requirement: [...]

Inspectors wroteBased on record review and interview, the facility failed to maintain an accurate accounting of all monies held in the resident trust fund account by not reconciling each month. The facility managed funds for 95 residents. The facility census was 137. Record review of the facility maintained bank statements for months 01/2023 through 12/2023, showed no documentation of complete reconciliations with a zero balance. Record review of the facility maintained reconciliation forms, dated 01/2023 through 12/2023, showed the attempted reconciliations did not reconcile to the residents' current balance at the time of reconciliation. During an interview on 2/07/24 at 9:15 A.M., the Business Office Assistant said they were working on clearing out old checks that went back at least two years. [...]

Inspectors wroteBased on observation and interview, the facility failed to follow their policy by not maintaining grievances for three years. The sample was 27. The census was 137. Review of the facility's Resident Grievance Policy, dated 9/2/16, showed: -Grievance: an official statement of a complaint over something believed to be wrong or unfair; -Grievance Official: The person designated by the Administrator to receive all grievances to be investigated by the grievance committee. This role defaults to the Director of Social Services unless otherwise designated differently by the Administrator; -Policy: This facility will provide a venue for residents, and others involved in patient care, to voice concerns, complaints, or grievances to facility leadership and external parties; -Procedure: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and ensure newly hired employees were screened to determine the presence of a federal indicator with the Nurse Aide Registry (NA) check for three of 10 sampled employees hired since the last survey. The facility hired at least 648 new employees since the last survey. The census was 137. Review of the facility's undated Missouri Abuse, Neglect and Misappropriation Policies and Standard Procedures, showed: -Policy: It is the intent of this facility to prevent the abuse, mistreatment, or neglect of residents or the misappropriation of their property and to provide guidance to direct staff to manage any concerns or allegations of abuse, neglect or misappropriation of their property. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized care plans to address specific needs of the residents for 12 of 27 sampled residents (Residents #100, #63, #104, #72, #30, #91, #281, #117, #20, #69, #79 and #109). In addition, the facility also failed to hold care plan meetings in a timely manner. The census was 137. Review of the facility's undated Plan of Care Overview Policies and Standard Procedures, showed: -Definitions: The plan of care, also care plan is the written treatment provided for a resident that is resident-focused and provides for optimal personalized care; -Policy: It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents; -Procedure: General Care Planning Goals and Guidelines; [...]

Inspectors wroteBased on observation and interview the facility failed to ensure services provided met professional standards of practice when staff failed to discard expired intravenous (IV, medical technique that administers fluids, medication, and nutrients directly into the vein) therapy supplies, in two of two medication rooms checked. The facility had four medication rooms. The census was 137. Observation of the cabinets in the Rehab Hall medication room, on [DATE] at 10:16 A.M., showed: -IV therapy supplies placed in a black storage bin with a yellow lid. The contents of the storage bin included: -DermaView II Transparent Film dressing (a moisture-vapor permeable transparent dressing that aids in the prevention of bacterial contamination), 14 pieces, expired [DATE]; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who required assistance with activities of daily living (ADLs), were provided adequate assistance during meals (Resident #27 and Resident #13). The facility also failed to ensure one resident (Resident #72) received assistance with personal care, hygiene and showers to meet the resident's needs. The sample was 27. The census was 137. Review of the facility's Routine Resident Care policy, undated, showed: -It is the policy of this facility to promote resident centered care by attending to the total medical, nursing, physical, emotional, mental, social, and spiritual needs and honor resident lifestyle preferences while in the care of this facility; -Definition: Routine Resident Care: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure bed rails were accurately assessed as a necessary device prior to installation and use for three sampled residents (Residents #72, #117 and #20). The facility also failed to document usage in the residents' care plans. The sample was 27. The census was 139. Review of the facility's undated Safe Use of Bed Rails Policies and Standard Procedures, showed: -Definitions: Bed rails are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of type, shapes and sizes ranging from one-half, one-quarter, or one-eighth lengths. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored per acceptable standards of practice. The facility identified 11 medication/treatment carts and four medication rooms. Six of the 11 carts and two medication rooms were checked for medication storage. Issues were found in the medication rooms and in the medication carts. Staff failed to separate medications and food storage in the medication room refrigerators, date an opened vial of tuberculin purified protein derivative (PPD, used to diagnose silent (latent) tuberculosis (TB) infection) solution and insulin solution (used to treat high blood sugar) vials and pens. Staff failed to keep Lorazepam (used to treat anxiety) liquid medication in the refrigerator. and place two locks on the substance controlled medication storage. The census was 137. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the pureed (cooked food that has been ground, pressed, blended or sieved to the consistency of a creamy paste or liquid) diet recipe, and ensure residents on pureed diets were served a pureed diet. This practice affected 7 residents with pureed diets. The census was 137. Review of the Therapeutic Diets Policy, undated, showed: -Policy Statement: All residents have a diet order, including regular, therapeutic, and texture modification, that is prescribed by the attending physician, physician extender, or credentialed practitioner in accordance with applicable regulatory guidelines. -Definitions: Therapeutic diet is defined as a diet ordered by a physician, or delegated registered or licensed dietitian, as part of the treatment for a disease or clinical condition. [...]

Inspectors wroteBased on observation and interview, the facility failed to serve food under sanitary conditions by not ensuring staff followed proper hand hygiene techniques, by not changing gloves and washing hands, touching the surface of plates and utensils with soiled gloved and bare hands, and touching food items with soiled gloved hands. These deficient practices had the potential to affect all residents who ate at the facility. The census was 137. Review of the Facility Handwashing Procedure for Dining Services Policy, undated, showed: -Purpose: To provide personnel with a simple, practical and easy-to-implement procedure for hand washing on the units, in the kitchen, or in the dining room; -The following is a list of some situations that require hand hygiene: -When coming on duty; -After handling soiled equipment or utensils; -After removing gloves or aprons; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff completed routine and resident specific inspections of bed frames, mattresses and bed rails as part of a routine maintenance program, to identify possible areas of entrapment for 12 of 27 sampled residents (Residents #281, #3, #63, #100, #117, #20, #30, #91, #104, #72, #79 and #69). The census was 137. Review of the facility's Safe Use of Bed Rails Policy, undated, showed: -Definition: Bed Rails: are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of type, shapes, and sizes ranging from full to one-half, one-quarter, or one-eighth lengths. Also, some bed rails are not designed as part of the bed by the manufacturer and may be installed on or used along the side of a bed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to uphold the rights to a dignified existence and self determination were honored for two residents when a resident with contracted (a fixed tightening of muscle, tendons, ligaments, or skin) hands was not assisted with eating, resulting in the resident eating off of the table (Resident #27). In addition, staff failed to ensure a visually impaired resident knew the location of his/her utensils, resulting in the resident eating with his/her hands (Resident #13). This had the potential to affect all residents who required assistance with eating. The sample was 27. The census was 137. 1. Review of Resident #27's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/10/23 showed: -Cognitively impaired; -Eating: [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the physician when one resident's blood sugar level was outside the parameters as ordered (Resident #282). The census was 137. Review of the facility's undated Physician Orders policy, showed to notify the attending or other providers as appropriate. Document contacts in the medical record. Review of Resident #282 admission Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) dated 2/8/23, showed: -Cognitively intact; -Diagnoses included: diabetes, kidney insufficiency, malnutrition, and depression; Review of the resident's care plan, in use at the time of survey, showed: -Focus: Resident has diabetes, type 2 (adult on-set) diabetes mellitus; -Goal: Will be free from any signs of symptoms of hypoglycemia (low blood sugar)/ hyperglycemia (high blood sugar) through next review; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screen and Resident Review (PASARR) Level II screen was completed prior to admission for one of 27 sampled residents (Resident #69). This created a potential failure to identify what specialized or rehabilitative services the resident needed and whether placement in the facility was appropriate prior to admission. The census was 137. Review of the facility's PASRR policy, dated 8/11/2020 and reviewed on 8/14/2020, showed: -PASRR is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. PASRR requires that Medicaid-certified nursing facilities develop the PASRR program to prevent inappropriate admission and retention of people with mental disabilities in nursing facilities; -Policy: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide wound care per acceptable standards of practice for one closed record sampled resident (Resident #282) investigated for wounds when staff failed to obtain treatment orders and/or transcribe physician orders accurately or timely after a resident was admitted with wounds. The census was 137. The administrator was notified on 2/13/24, of the past non-compliance. The facility hired a full-time wound nurse in May of 2023. The facility identified an issue with wounds in June 2023. The facility did a full facility audit and obtained a contract for a new wound company. The new wound company started in July 2023. Staff was in-serviced on the new practices and the new practice was posted at the nurse's station. The deficiency was corrected on 7/23/23. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pressure ulcer (injury to the skin and/or underlying tissue, as a result of pressure or friction) care and assessment per acceptable standards of practice for one closed record sampled resident (Resident #282) investigated for wounds when staff failed to obtain treatment orders and/or transcribe physician orders accurately or timely after the resident was admitted with pressure ulcers. The census was 137. The administrator was notified on 2/13/24, of the past non-compliance. The facility hired a full-time wound nurse in May of 2023. The facility identified an issue with wounds in June 2023. The facility did a full facility audit and obtained a contract for a new wound company. The new wound company started in July 2023. Staff was in-serviced on the new practices and the new practice was posted at the nurse's station. [...]

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 two residents (Residents #30 and #117). The census was 137. Review of the facility's undated Restorative Programs policy, showed: -It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents; -Safety is a primary concern for the residents, staff and visitors; -The purpose of this policy is to provide direction and guidance to the clinical team to assess and implement a plan of action for resident-specific care to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide one resident with a therapeutic tube feeding (a tube inserted directly into the stomach to provide food, fluids, and medications when one cannot eat or drink safely by mouth) diet as ordered for one resident (Resident #281) investigated for nutrition via a gastric tube (g-tube) of six residents identified by the facility as receiving tube feedings. The census was 137. Review of the facility's Enteral General Nutritional Guidelines policy, dated 9/21, showed: -Definitions: Feeding Tube: for the purpose of this policy, a feeding tube is an external device surgically placed through an artificial opening in the abdominal wall for the purpose of nutrition, hydration and/or medication delivery; -Policy: Enteral feedings are provided by bolus (intermittent), or continuous delivery. [...]

Inspectors wroteBased on interview and record review, facility staff failed to obtain stop dates of 14 days or less, on PRN (as needed) psychotropic medications (a chemical substance that changes brain function and results in alterations in perception, mood, consciousness or behavior) for two residents (Resident #5 and Resident #69). The sample was 27. The census was 137. Review of the facility's Medication Regimen Review Policy, undated, showed: -Definitions: Non-urgent medication irregularities: items that will be addressed with the attending physician in a manner that meets the needs of the resident, but no later than their next routine visit to assess the resident or 60 days whichever is sooner; -Unnecessary drug: Any drug when used: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from significant medication errors, when staff failed to administer one resident's nicotine patch, which caused the resident discomfort (Resident #72). The sample was 27. The census was 137. Review of the facility's Medication Administration Policy, undated, showed: -It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents; -The purpose of this policy is to provide guidance for general medication administration to be provided by personnel recognized as legally able to administer; -Administer medication only as prescribed by the provider. Review of Resident #72's admission Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 1/8/24, showed: [...]

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 nine of 11 residents reviewed, who expired and had money in their account (Residents #700, #701, #702, #703, #704, #705, #706, #707 and #708). The census was 181. 1. Review of Resident #700's resident fund account, showed the following: -He/she expired on [DATE]; -He/she had a balance of $1,676.26; -TPL completed [DATE]. 2. Review of Resident #701's resident fund account, showed the following: -He/she expired on [DATE]; -He/she had a balance of $46.03; -TPL completed [DATE]. 3. Review of Resident #702's resident fund account, showed the following: -He/she expired on [DATE]; -He/she had a balance of $1,537.16; -TPL completed [DATE]. 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized care plans, to address specific needs of the residents, for seven of 38 sampled residents (Residents #156, #12, #71, #133, #64, #2 and #323). The census was 181. 1. Review of Resident #156's admission Minimum Data Set (MDS), a federally mandated asessment instrument completed by facility staff, dated 1/25/2021, showed: -admission date of 1/16/2021; -Cognitively intact; -Diagnosis included diabetes. Observations on 3/1/2021 at 10:00 A.M., 3/2/2021 at 8:20 A.M., and 3/3/2021 at 1:30 P.M., showed the resident had an insulin pump connected to his/her abdomen. During an interview on 3/1/2021 at 10:00 A.M., the resident said he/she had an insulin pump since 1998 and is able to manage it by him/herself. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care and services were provided according to accepted standards of clinical practice by not administering medications per their medication administration policies for 15 residents (Residents #12, #25, #33, #35, #71, #73, #78, #83, #94, #98, #110, #126, #139, #156, and #322.) The facility failed to document the provision of restorative therapy services, correctly label tube feeding bottles, obtain orders for a hand splint, and/or follow physician's orders for two additional residents (Resident #2 and #323). The facility also failed to develop and implement an admissions procedure which included timely initial assessement, verification of orders and initiation of a baseline care plan. This affected one resident (Resident #800), who was admitted to the facility. The sample size was 38. The census was 181. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary services, care or assistance for dependent residents who were unable to perform activities of daily living (ADLs). The facility failed to ensure three residents received necessary services to maintain good nutrition (Residents #91, #93 and #121) and failed to maintain grooming and personal/oral hygiene for four sampled residents (Residents #31, #65, #147 and #326). The sample was 38. The census was 181. 1. Review of Resident #91's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/1/21, showed: -Diagnoses of dementia, Parkinson's disease and high blood pressure; -Short/long term memory loss; -Extensive staff assistance with bed mobility, dressing, eating and personal hygiene; -Total staff assistance for transfers; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all open insulin pens/vials and inhalers had an open date written on it for four out of eight observed open insulin pens/vials and two of two observed open inhalers; failed to ensure all emergency swing kits (portable emergency medication kits provided by the pharmacy) and the medications inside of the emergency swing kits were not expired; and failed to ensure all medications and treatment supplies were not expired in three of four observed medication rooms. This deficient practice has the potential to affect all residents admitted to the facility. The sample size was 38. The census was 181. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide residents with a nourishing, well-balanced diet, taking into consideration each resident's preferences. The facility failed to respect each resident's right to make choices about his/her diet and be provided with acceptable alternative choices or substitutions for four sampled residents (Residents #61, #28, #133 and #86). The sample was 38. The facility census was 181. 1. Review of Resident #61's Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 12/11/20, showed the following: -Cognitively intact; -Independent with with activities of daily living (ADLs, self care activities); -Diagnoses included depression, high blood pressure, muscle weakness; -Mobility device: None used. [...]

Inspectors wroteBased on observation and interview, the facility failed to store and prepare food in accordance with professional standards for food service by failing to ensure thawed foods were correctly dated to prevent the use of outdated food items, by failing to ensure utensils were not placed on contaminated surfaces in between use, ensure equipment was air dried, and ensure staff properly wore hair restraints to cover their hair while in the kitchen. In addition, the facility failed to ensure there was an air gap between the ice machine's drain and the floor drain, in one of two kitchens, to potentially prevent sewer water from backing up into the industrial ice maker. The census was 181. 1. Observation of the south kitchen on 2/18/21, showed: -At 11:25 A.M., on the exterior of the refrigerator, located behind the hand washing sink, a sign which read, open date, use by date, blank; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff completed routine inspection of bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for five residents (Residents #121, #326, #71, #108, #87) with side rails to reduce the risks of accidents. The facility identified 124 residents with side rails in use. The census was 181. 1. Review of Resident #121's quarterly Minimum Date Set (MDS), a federally mandated assessment instrument completed by staff, dated 1/9/21, showed the following; -Rarely or never understood; -Long and short term memory problems; -Severely impaired cognitive skills; -Required extensive assistance of two or more persons for bed mobility, transfers, and eating; -Impairment on both sides of the upper and lower body; -Bed rails not used. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure residents had privacy curtains that provided full visual privacy for residents. This had the potential to affect 20 residents residing in 10 semi-private rooms on one of five halls/wings. The census was 181. During the initial facility tour on 2/18/21 at 11:43 A.M., resident rooms: 47, 48, 50, 52, 54, 56, 63, 65, 67 and 69, all semi-private rooms with all beds occupied, were observed to have one privacy curtain, approximately 8 feet long between each bed. The privacy curtains were attached to one tract on the ceiling that ended at the foot of the two beds. The tracts did not curve around either bed in the room to provide full privacy to either resident for their own personal use, or when staff provided personal care. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life when staff failed to honor a resident's request (Resident #68) for the removal of an indwelling catheter (a sterile tube inserted into the bladder to drain urine) after expressing it was embarrassing to have and remained in place without a diagnosis, refused to provide a resident as needed (PRN) pain medication when requested (Resident #147), refused to assist a resident to the bathroom when requested (Resident #64), failed to provide assistance with grooming and dressing for a dependent resident who remained in soiled clothing (Resident #82) and remained on a personal cell phone while discussing a resident's protected health information [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to promote and facilitate resident self-determination through support of resident choice, by failing to facilitate a resident's right to make choices about aspects of his/her life that are significant to the resident, when the facility staff opened a resident's package without the resident's permission (Resident #86). Staff also failed to honor a resident's choice to get out of bed, resulting in the resident remaining in bed all day (Resident #133). The sample size was 38. The census was 181. 1. Review of Resident #86's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/17/20, showed the following: -Cognitively intact; -Makes self understood and is able to understand others; -Independent with all activities of daily living (ADLs, self care activities); [...]

Inspectors wroteBased on interview and record review, the facility failed to notify a family member timely of a resident's fall and laboratory results, for one expanded sample resident (Resident #323). The census was 181. Review of Resident #323's admission Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff dated 3/2/20, showed the following: -Brief Interview of Mental Status, (BIMS, a brief screen of cognitive status) score of 3 (severe cognitive impairment); -Delusions; -Diagnoses included atrial fibrillation (A-fib, an irregular, often rapid heart rate that commonly causes poor blood flow), heart failure, arthritis and dementia. Review of the resident's progress notes, dated 3/28/20, showed the following: -At 2:45 A.M., the nurse heard a bump, went to observe, and noticed the resident on his/her knees in front of the toilet. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide evidence that residents' personal possessions had been returned to the resident or resident representative upon discharge or death. The Inventory of Personal Effects forms of three discharged residents were reviewed and problems were found with all three. (Residents #575, #226 and #223). The census was 181. 1. Review of Resident #575's medical record, showed: -The resident was admitted to the facility [DATE]; -Diagnosis included: traumatic brain injury (brain dysfunction caused by an outside force, usually a violent blow to the head), atrial fibrillation (a-fib, irregular heart rhythm) dementia, repeated falls, and high blood pressure; -The resident expired on [DATE]. Review of the Resident's Inventory of Personal Effects, showed: -Items acquired after original entry, dated 7/20, an echo hub was listed; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure newly hired employees had complete criminal background checks and were screened to rule out the presence of a Federal Indicator with the Certified Nurse Aide (CNA) Registry for three of eleven employee files reviewed. Furthermore, the facility failed to have a policy to address routine reviews of the employee disqualification list (EDL, a listing maintained by the Department of Health and Senior Services (DHSS) of individuals who have been determined to have abused or neglected a resident, patient, client, or consumer or misappropriated funds or property belonging to a resident, patient, client, or consumer) to ensure no current employees have been added to the EDL. The census was 181. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy by thoroughly investigating a resident's allegation of physical abuse by a facility staff member and submit to the Department of Health and Senior Services (DHSS) their investigation (Resident #424). This deficient practice had the potential to affect all residents residing in the facility. The sample was 38. The census was 181. Review of the facility's Abuse, Neglect and Misappropriation Policy, dated 10/14/14, revised on 10/12/18 and 3/21/19, showed: -Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, or good or services that are necessary to attain or maintain physical, mental and psychosocial well-being. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident of 38 sampled residents was monitored and interventions were implemented to ensure his/her safety, and the safety of other residents in the facility, related to the resident's illicit drug use in the facility (Resident #71). This deficient practice had the potential to affect all residents admitted to the facility. The census was 181. 1. Review of Resident #71's quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 12/12/20, showed: -admission date of 9/4/20; -Mild cognitive impairment; -No behaviors affecting self or others; -Diagnoses included anxiety disorder, bipolar disease and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nursing staff had training and maintained appropriate competencies and skill sets to provide oversight and care of one resident admitted with an insulin pump (Resident #156). The sample was 38. The census was 181. Review of Resident #156's medical record, showed: -admission date of 1/16/21; -Diagnosis included diabetes; -An order dated, 2/22/21; resident may manage personal insulin pump. Observations showed the resident had an insulin pump secured to the left side of his/her abdomen at various times during the survey on 3/1 through 3/3/21. During an interview on 3/1/21 at 10:00 A.M., the resident said he/she has had an insulin pump since 1998. He/she is able to fill the insulin cartridge, change the insulin pump tubing and manage the settings of the pump without difficulty. [...]

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 31 opportunities for error, two errors occurred, resulting in a 6.45% medication error rate (Resident #166). The facility census was 181. 1. Review of Resident #166's admission Minimum Date Set (MDS), a federally mandated assessment instrument completed by staff, dated 1/18/21, showed the following: -Alert and oriented and able to make decisions; -Diagnoses included atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), heart failure (chronic condition in which heart does not pump blood as well as it should) and septicemia (a life-threatening complication of an infection). Review of the resident's physician orders (POS), dated 2/22/21, showed the following: [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain an effective pest control program to prevent gnats in one resident's room on the South hall (Residents #83), throughout the facility's South hall and near the South hall nurse's station, where staff provided feeding assistance to one resident (Resident #121) and one resident's room on the North hall (Resident #139). The sample was 38. The census was 181. 1. Review of Resident #83's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/17/20, showed: -admitted on [DATE]; -Cognitively intact; -Diagnoses included anxiety and depression. Observations on 2/19/21 at 12:35 P.M. and on 2/23/21 at 1:25 P.M., showed several gnats flying throughout the resident's room, on the South hall. No odors were present in the room. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the state abuse/neglect hotline phone number and the Medicare/Medicaid contact information was posted in a prominent location for residents, visitors and staff. The sample was 38. The census was 181. 1. Observations of the halls in the rehabilitation building, the north and south halls in the long-term care building, and resident common areas in both buildings, on all days of the survey from 2/18-19, 2/22 through 2/26, and 2/28 through 3/3/21, showed no posted information for the state abuse/neglect hotline or Medicare/Medicaid contact information. 2. During the Resident Council interview on 2/23/21 at 8:19 A.M., three out of three residents said they did not know where the state abuse/neglect hotline or Medicare/Medicaid contact information was posted. 3. [...]