Brookfield Health Care Center

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that one resident (Resident #1), who had a diagnosis of diabetes mellitus (DM, a metabolic disease) and end-stage renal disease (ESRD, chronic irreversible kidney failure), who was receiving dialysis (a medical treatment that filters waste, extra salt, and fluid from the blood when the kidneys stop working) in a review of six sampled residents, received treatment and care per the facility's hemodialysis policy, when staff did not complete a pre-dialysis assessment that included a blood sugar finger stick (BSFS), did not offer the resident food prior to leaving the facility when the resident said he/she was hungry, and did not communicate with staff of the dialysis center when the resident was left in the lobby of the dialysis facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the physician, timely, for one resident (Resident #3), in a review of four sampled residents, when the resident's continuous positive airway pressure (CPAP, a machine that keeps the airway open during sleep for persons with sleep apnea) mask broke on 1/24/26. The resident went 12 days in the facility without using the CPAP at night, due to not having a functioning mask available. The facility also failed to notify the physician when the resident experienced a change in condition on 01/31/26, which included low oxygen saturation, lethargy and anxiety. Staff sent the resident to the hospital on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #1), in a review of nine sampled residents, received care and treatment in accordance with professional standards of practice when the resident presented with stroke like symptoms including facial drooping on the left side, slurred speech, delayed responses, and left sided weakness on 8/25/25. The Director of Nursing (DON) advised the resident's family that given the resident's age, treatment would potentially be limited. The facility failed to send the resident to the hospital for evaluation. The resident sustained a stroke and the resident's functional abilities declined as a result. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to use a gait belt (a canvas belt placed around the resident's waist to assist with ambulation and transfers), appropriately when transferring one resident (Resident #8) in a review of 16 sampled residents. Additionally, staff failed to reposition one resident (Resident #8), appropriately when staff lifted the resident by pulling on his/her pants. Staff failed to use a gait belt to transfer two residents (Resident #8 and #17) and instead, pulled on the resident's arms, back of neck and shoulders when assisting the resident from sitting to standing. The facility failed to store a portable oxygen tank securely when not in use for one resident (Resident #25). The facility census was 25. Review of the facility's policy, Safe Resident Handling Transfers Policy, revised 05/14/24, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to provided a Registered Nurse (RN) eight consecutive hours a day, seven days a week. Additionally the facility failed to have a full time Director of Nursing (DON) from 05/10/25 through 06/09/25. The facility census was 25. Review of the facility's policy, Sufficient Staff Policy, revised 05/18/24, showed the following: -It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident; -Except when waived, the facility must use the services of an RN for at least eight consecutive hours a day, seven days a week; -The DON may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each certified nurse assistant (CNA) had no less than 12 hours of in-service education per year based on their individual performance review, calculated by hire date. Five of five CNAs (CNA H, CNA F, CNA I, CNA J and CNA D) sampled did not have the required 12 hours of in-service education. The facility census was 25. Review of the facility's policy, Nursing Aide Training Program Policy, revised 05/18/24, showed the following: -This facility maintains an appropriate and effective nurse aide in-service training program for the purpose of ensuring the continuing competence of nurse aides; 1. The facility, with oversight from the Director of Nursing (DON), shall be responsible for the coordination and/or provision of nurse aide education; 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food service equipment and kitchen/food storage room surfaces were appropriately cleaned to ensure sanitary conditions in accordance with professional standards for food service safety. The facility census was 25. 1. Observations on 06/09/25 between 10:00 A.M. and 2:13 P.M., and on 6/10/25 between 6:00 A.M. and 6:30 A.M., in the kitchen and dietary storage room showed the following: -The top surface of ice machine was dusty and soiled with debris. There was a white scaly material on the outside surface above the door hinge. The seal to the underside of ice machine door separated from the door and hung on the outside front surface of the machine; -The top, sides, and front of the upright refrigerator and freezer located in the kitchen, was soiled with food splatters, dust and debris. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a policy to address Legionella Control that included specific control parameters based on Center for Disease Control (CDC) an American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) standards, failed to develop a water management team that conducted meetings and failed to complete a water flow map. Additionally, the facility failed to ensure nursing staff washed their hands and changed soiled gloves after each direct resident contact and when indicated by professional standards of practice during care for two residents (Resident #8 and #24), in a review of 16 sampled residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain a system to ensure four discharged residents' (Residents #101, #102, #103 and #28) personal funds were not maintained in the facility's operating account when the facility did not reimburse the residents and/or their responsible parties after the residents were discharged from the facility. The facility census was 25. Review of the facility policy, Resident Trust, revised 06/12/25, showed the following: -Upon admission, an Authorization to Hold Resident's Funds form (Attachment M in the admission Contract) must be presented to the resident, guardian, or legal representative and must be signed by them if they choose to have the facility manage the resident funds; -The facility shall keep an accurate and maintained accounting system for the residents that choose to have their personal funds managed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to repair or paint areas to maintain a homelike environment in resident rooms #101, #404 and #207. The facility census was 25. Review of the facility policy, Safe and Homelike Environment, dated 06/05/25, showed the following: -In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment; -Environment refers to any environment in the facility that is frequented by residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas; [...]

Inspectors wroteBased on interview and record review, the facility failed to complete required employee background screenings including criminal background checks (CBC) and employee disqualification list (EDL) checks, prior to employment for four of ten newly hired employees (Housekeeper P, Certified Medication Technician F, Assistant Director of Nurses, and Certified Nurse Aide J -hired since the last survey). The facility also failed to check the Nurse Aide Registry for the Administrator as directed in the facility policy. The facility census was 25. Review of the facility's policy Background Investigations, last revised 12/27/24, showed the following: -Criminal conviction record checks are conducted on all personnel making application for employment with this company; [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a significant change in status assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment tool required to be completed by facility staff, for three residents (Resident #4, #11, and #14), in a review of 16 sampled residents. This assessment should have been completed within 14 days after the facility determined, or should have determined, there had been a significant change (a decline or improvement in two or more assessed areas of resident status) in the resident's physical or mental condition which had an impact on more than one area of the resident's health status, and required interdisciplinary review and/or revisions of the care plan. The facility census was 25. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive, person-centered care plan for four residents (Resident #5, #11, #23 and #4), in a review of 16 sampled residents. The facility census was 25. Review of the facility policy, Comprehensive Care Plans, revised 10/31/24, showed the following: -It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the resident's comprehensive assessment; -Person-centered care means to focus on the resident as the focus of control and support the resident in making their own choices and having control over their daily lives; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to update and revise problems and interventions on resident care plans to reflect current care needs for three residents,(Resident #4, #14 and #15), in a review of 16 sampled residents. The facility census was 25. Review of the facility policy, Comprehensive Care Plans, revised 10/31/24, showed the following: - It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the resident's comprehensive assessment; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician's orders for four residents (Resident #10, #16, #23, and #24) in a sample of 16 residents, and one additional resident (Resident #23). The facility census was 25. Review of the facility policy Transcription of Orders/Following Physician's Orders, last revised 05/18/24, showed the following: -The purpose of this policy is to ensure that all physicians' orders are followed; -To ensure a process is in place to monitor nurses in following physician's orders; -The Licensed Nurse will review electronic Medication Administration Records (MARs) & electronic Treatment Administration Records (TARs) on a routine basis to monitor for medications that were not administered to the resident due to unavailability, refusal, omission, etc. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure code status matched on all resident documents and their door name plates to ensure staff responded appropriately to provide or not provide Cardio Pulmonary Resuscitation (CPR) (an emergency procedure that combines chest compressions and rescue breathing to restart a person's breathing and heartbeat) according to the resident's wishes if the resident was found without a heart beat or respirations for four residents (Resident #20, #22, #24, and #229) in a sample of 16 residents. The facility census was 25. Review of the facility policy, Communication of Code status, last revised [DATE], showed the following: -It is the policy of this facility to adhere to residents' rights to formulate advance directives; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient staffing to ensure one dependent resident (Resident #24) was able to smoke outside, ensure residents received restorative services or to ensure call lights were answered timely to accommodate resident needs for five residents (Resident #5, #13, #16, #22, and #24) in a review of 16 sampled residents. The facility census was 25. Review of the facility's policy, Call Lights Accessibility and Timely Response, revised 04/30/24, showed all staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desired, the appropriate personnel should be notified. During an interview on 06/12/25 at 7:30 P.M., the Assistant Director of Nursing (ADON) said the facility had no restorative program at this time. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow an antibiotic stewardship program as part of their infection prevention and control program that included antibiotic use protocols and a system to monitor antibiotic use for two residents (Resident #229 and #15), in a review of 16 sampled residents. The facility census was 25. Review of the facility policy, Antibiotic Stewardship Program, dated 06/29/23, showed the following: -To optimize antibiotic use in our nursing home and reduce unnecessary use of laboratory tests and antibiotics using a systematic approach; -This Facility Antibiotic Stewardship Program (ASP) will comply with all state and federal laws and regulations; -The ASP will be run by the Facility Antibiotic Steward, who will lead the Antibiotic Stewardship Team (AST); [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pneumococcal vaccinations (a vaccine that can protect against pneumococcal disease) as indicated by the current Centers for Disease Control and Prevention (CDC) guidelines for four residents (Residents #15, #5, #229 and #4), of five residents reviewed for immunization status. Resident #15 developed symptoms of lethargy (a state of sleepiness or unresponsiveness) and decreased oxygen saturation (the measurement of oxygen circulating in the blood), resulting in a trip to the emergency room and a diagnosis of pneumonia, the resident was not up to date with pneumonia vaccines according to CDC guidelines. The facility census was 25. Review of the facility's policy Pneumococcal Immunizations, revised 05/14/2024, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff training needs as identified in the facility assessment and the facility staff development plan were met. The facility also failed to ensure 12 hours of training were completed per calendar year to include dementia management and resident abuse prevention training per year for five certified nursing assistants (CNA)'s (CNA H, CNA F, CNA I, CNA J and CNA D), in a sample of five CNA's who have been employed over a year. The facility census was 25. Review of the facility's policy, Nursing Aide Training Program Policy, revised 05/18/24, showed the following: -This facility maintains an appropriate and effective nurse aide in-service training program for the purpose of ensuring the continuing competence of nurse aides; [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS), a federally mandated assessment completed by staff, according to the Resident Assessment Instrument (RAI) manual for two residents (Resident #24 and #27), in a review of 16 sampled residents and one closed record. The facility census was 25. Review of the Centers for Medicare and Medicaid Services (CMS), Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.18.11, Chapter 2, revised October 2023, showed the following: -Medicare and Medicaid participating LTC facilities are required to conduct comprehensive, accurate, standardized and reproducible assessments of each resident's functional capacity and health status; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and provide a copy of a complete baseline care plan, consistent with the resident's specific conditions, needs and risks that provide effective person-centered care that met professional standards of quality of care within 48 hours of admission to the facility for one resident (Resident #229), in a review of 16 sampled residents and one additional resident (Resident #23). The facility census was 25. Review of the facility policy, Baseline Care Plan, revised 05/18/24, showed the following: -The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care; -The baseline care plan will: -Be developed within 48 hours of a resident's admission; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to provide range of motion for limited mobility to one or more affected areas to increase range of motion (ROM), or prevent further decrease in range of motion for one resident, (Resident #13), in a review of 16 sampled residents. The resident said his/her contractures (permanent tightening of muscles, tendons, skin and other tissues, resulting in stiff and shortened joints that restrict normal movement) had gotten worse since he/she had been in the facility and now he/she had knots and pain in his/her arm and shoulder that are worse because of the contractures. He/She feared he/she will get more contractures and have more pain or skin issues. The facility census was 25. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to conduct a complete assessment to identify a history of trauma, the presence of symptoms related to the trauma, and triggers that may cause re-traumatization and to develop an individualized care plan with interventions to mitigate and eliminate these triggers for two residents (#13 and #23), in a review of 16 sampled residents. The facility census was 25. Review of the facility policy, Trauma Informed Care, revised 05/14/24, showed the following: -It is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally-competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one nurse aide (NA G), of one NA reviewed, completed a certified nurse aide (CNA) training program within four months of their employment in the facility. The facility census was 25. Per email communication on 06/17/25 at 11:54 A.M., the facility administrator said to his knowledge the facility did not have a policy addressing nurse aide certification within four months of employment. 1. Review of the facility provided list of employees hired since the last annual survey, showed NA G was hired on 12/12/24. 2. Review of NA G's employee file showed no documentation he/she completed a CNA training program within four months of his/her hire date. 3. Review of NA G's nurse aide registry check showed no documentation to show NA G had a CNA certification. 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles when facility staff failed to date the label of multi-use vials of insulin (injectable medication to treat diabetes (inability to regulate blood sugar(glucose)) when first accessed and administered insulin from the opened, undated multi-use vial of insulin. Further review showed staff administered undated or expired insulin to one resident, (Resident #19), in a review of 16 sampled residents and one additional resident (Resident #23). The facility census was 25. Review of the facility policy, Administration Of Insulin Policy, revised 05/14/24, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice to four residents (Resident #5, #15, #24 and #25) or the resident representatives, in a sample of four residents reviewed related to discharge or transfer, that included the reason for discharge/transfer, location being discharged /transferred to, resident's appeal rights and who to contact for an appeal hearing request, the contact information for the Ombudsman, the contact information for the advocacy agency for residents with intellectual and developmental disabilities or the contact information for the agency that is an advocacy for residents with mental illness. [...]

Inspectors wroteBased on observation and interview, the facility failed to comply with state laws and designate a person as an administrator who was employed in the facility and served in that capacity on a full-time basis. This had the potential to affect all facility residents. The facility census was 30. 1. Observation on [DATE] at 9:00 A.M., outside the office labeled Administrator, showed the following: -The Assistant Administrator occupied the Administrator's office; -A State of Missouri Licensed Nursing Home Administrator License was displayed with the Administrator's name (the name on the license was not the assistant administrator's name, who was acting as the administrator); -The license was issued on [DATE] and expired on [DATE]. During an interview on [DATE] at 9:15 A.M. the Maintenance Director said the following: -The Assistant Administrator was an administrator in training; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. Staff failed to properly thaw potentially hazardous foods in order to prevent cross-contamination by not storing raw meat separately from fully cooked food items. Staff failed to store and handle food products to maintain quality and keep them free from potential contaminants by not properly sealing opened food items and not discarding dropped food items. Staff failed to ensure hygienic practices when preparing food for residents by not employing proper hand hygiene or thermometer probe sanitizing. Staff failed to ensure the kitchen ice machine's drain contained a sufficient air gap to prevent potential backflow into the machine. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a plan of care consistent with resident's specific conditions, needs, and risks to provide effective person-centered care for three residents (Residents #15, #23 and #28), in a review of 13 sampled residents, and one additional resident (Resident #3). The facility census was 31. Review of the facility policy, Care Plans, Comprehensive Person-Centered, dated December 2016, showed the following: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; -Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change; -The Interdisciplinary Team must review and update the care plan: a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff provided grooming and hygiene needs for three residents (Residents #5, #6, and #12) and one additional resident (Resident #82), who were unable to perform their own activities of daily living (ADLs), in a review of 13 sampled residents. The facility census was 31. Review of the facility policy, Mouth Care - AM (morning), PM (afternoon/evening) and PRN (as needed), dated October 2010, showed the following: -The purpose of this procedure is to keep the resident's lips and oral tissues moist, to clean and freshen the resident's mouth, and to prevent infections of the mouth; -Review the resident's care plan to assess for any special needs of the resident. Review of the facility undated policy, Shaving the Resident, showed the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in a manner that enhanced resident dignity and ensured full recognition of individuality when facility staff failed to provide personal care or pain medication when requested for two residents (Resident #20 and #28), in a review of 13 sampled residents. The facility census was 31. Review of the undated facility policy, Quality of Life-Dignity, showed the following: -Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality; -Residents shall be treated with dignity and respect at all times; -Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth; -Staff shall speak respectfully to residents at all times. 1. Review of Resident #20's face sheet showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess the use of a lap buddy (a positioning device when the patient is unable to maintain upright position in the chair and is used to provide trunk and upper arm/body support for wheelchair mobility or self-feeding), as a restraint for one resident (Residents #12), in a review of 13 sampled residents, who was unable to easily and intentionally remove the lap buddy. The facility also failed to identify a medical symptom that supported the use of the restraint, and failed to develop a care plan for the lap buddy with interventions to minimize or eliminate the medical symptom and identify and address any underlying problems causing the medical symptom. The facility census was 31. Review of the facility's undated policy, Use of Restraints, showed the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to complete a significant change status assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment, required to be completed by facility staff, for two residents (Resident #5 and #15), in a review of 13 sampled residents. This assessment should have been completed within 14 days after the facility determined, or should have determined, there had been a significant change (major decline or improvement in the resident's status) in the resident's physical or mental condition which had an impact on more than one area of the resident's health status and required disciplinary review and/or revision of the care plan. The facility census was 31. Review of the Long Term Care Facility RAI User's Manual, version 3.0 showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to have documentation of a Level I (level of care) PASARR (Pre-admission Screening and Resident Review), and then failed to file for a Level II PASARR (an in-depth assessment of the resident's mental health and intellectual needs) when conditions/diagnoses changed or were added for one resident (Resident #4) in a review of 13 sampled residents. The facility census was 31. Record review of the Missouri Department of Health and Senior Services (DHSS) guide titled, PASARR Desk Reference, dated 3/3/08, showed: -The PASARR is a federally mandated screening process for any person for whom placement in a Medicaid Title (XIX) certified bed is being sought. This is a Level I screening (completion of the DA124C form). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician orders for one resident (Resident #3), who had an order for a decreased dose of medication, out of 13 sampled residents. Staff failed to follow policy to ensure the pharmacy label on the medication matched the physician's order resulting in staff administering the wrong dose of the medication. The facility census was 31. Review of the facility's undated policy, Administrating Medications, showed the individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Review of the facility undated policy for pharmacy notification, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate treatment and services consistent with acceptable standards of practice to prevent urinary tract infections (UTIs) for two residents (Residents #5 and #82), who had a urinary catheter (a sterile tube inserted into the bladder to drain urine), in a review of 13 sampled residents. The facility reported three residents with a urinary catheter. The facility census was 31. Review of the facility's undated and untitled policy showed the following: -It is the policy of the facility to provide pericare to all residents who are unable to provide for themselves; -Peri-care with a catheter: Wash the catheter tubing from the opening of the urethra outward 4 inches or farther if needed. Do not pull on the catheter; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare and serve bread and butter for any resident as directed in the approved menu. The facility census was 41. Review of the facility's undated policy on menus showed the menus are planned according to the basic four food groups and meet the standard requirements for nursing homes. Review of the menu for the noon meal on 01/28/20 showed staff was to serve crusted pork loin, roasted sweet potatoes, spinach bake, and bread and butter. All diets were to receive bread and butter. Observations on 01/28/20 between 12:03 P.M. and 12:46 P.M. showed staff served meal trays to all the residents. Staff did not serve bread and butter to any resident. During an interview on 01/28/20 at 1:01 P.M., [NAME] E said staff forgot the bread and butter. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the ovens and range hood baffles were free of buildup and debris. The facility census was 41. Observation on 1/28/20 at 9:24 A.M. showed the following: -The bottom in each of the two ovens was heavily soiled with a buildup of debris; -The baffle filters within the range hood had a heavy buildup of grease and debris. Review of the facility cleaning schedule (no date) showed oven #1 (oven #2 was not on the cleaning schedule) and the range hood filters were to be cleaned on week 1 and week 3. There was no documentation these areas had been cleaned. During interview on 1/28/20 at 3:02 P.M., the dietary manager said she was not aware there was a buildup of debris in the ovens, and was not aware there was a buildup of grease and debris on the range hood baffles. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserved nutritive value and flavor, and failed to serve food at a safe and appetizing temperature. The facility census was 41. Review of the facility's policy Food Temperatures, dated 01/16/08, showed correct serving temperatures for meats and vegetables/starches was 160 degrees Fahrenheit or greater. Review of the facility policy Nutrition Policies, dated 9/9/97, showed food is prepared to conserve nutritive value, flavor and appearance. 1. Review of the menu for the noon meal on 01/28/20 showed staff was to serve pork loin, sweet potatoes, and broccoli to residents on a pureed diet. (The facility identified four residents were to receive a pureed diet.) Review of the recipe for pureed pork loin showed to use chicken or beef base if the product needs thinning. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and effective form of medication control for one resident (Resident #14), in a review of 17 sampled residents, and for one additional resident (Resident #100). Staff did not administer medications as ordered, did not compare pharmacy label with physician orders during medication preparation and administration, and did not observe a resident swallow his/her medication. The facility census was 41. Review of the facility's policy, Policy for Medication Administration and Maintenance, dated December 2018, showed the following: -No medication or treatment shall be given without an order from a person lawfully authorized to prescribe such and the order shall be followed; -No medications will be left unattended or unobserved by certified medication technician (CMT) or nurse administering to residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control practices while performing blood glucose monitoring (Accucheck) for two residents (Residents #24 and #91), in a review of 17 sampled residents. The facility census was 41. Review of the facility's policy, Infection Control Competency Validation - Finger stick/Blood Glucose Monitoring, dated November 2017, showed the following: -Wash hands. Put on gloves; -Clean and disinfect meter by wiping with PDI Sani-Cloth germicidal wipes. Let meter air dry thoroughly before testing; -Remove one test strip from vial and insert in meter; -Lay meter and supplies on clean field (ex. paper towel) at resident's bedside; -Select fingertip. Clean area with an alcohol wipe. Let area dry; -Lance fingertip. Touch edge of sample tip to blood drop and allow blood to be drawn into strip; [...]