Buffalo Prairie Center for Rehab and Healthcare

Inspectors wroteBased on interview and record review, facility staff failed to have a process in place to ensure all resident's wishes regarding cardio-pulmonary resuscitation (CPR - an emergency procedure that is performed when a person's heartbeat or breathing has stopped) were honored when staff stopped performing CPR prior to Emergency Medical Services (EMS) arrival for one resident (Resident #1) who was found unresponsive. The facility census was 41. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident when staff staff documented one resident (Resident #1) received Cefdinir (antibiotic used to treat various bacterial infections, including pneumonia) for multiple days after the stop date. The facility staff also failed to ensure one resident (Resident #1) received prednisone (a potent steroid used to treat inflammation, severe allergies, autoimmune diseases, asthma, and certain cancers by suppressing the immune system and reducing swelling) as ordered when 10 of 11 possible doses were not documented. The facility had a census of 41. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to care plan and monitor a brain shunt (flexible tube surgically implanted to drain built-up fluid from the brain to another part of the body, helping relieve pressure in the brain), failed to ensure staff were aware of and trained in care of the shunt placement, failed to effectively address increased pain related to the resident's head, neck, and shoulder areas, and failed to notify the physician of increased head pain for one resident (Resident #1). The resident was sent to the hospital where the resident was taken to the operating room for shunt removal/replacement. The resident received a diagnosis of hydrocephalus (an abnormal buildup of cerebrospinal fluid (CSF) deep within the brain. This excess fluid causes the ventricles (cavities) within the brain to widen, putting harmful pressure on the brain's tissues). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with pressure ulcers (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing when the facility failed to timely assess and monitor, failed to obtain and document treatment orders, and failed to update the care plan regarding a facility acquired pressure ulcer that required surgical intervention for one resident (Resident #1). The facility census was 40. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide housekeeping services necessary to maintain a sanitary, orderly, and comfortable interior when odors, stains, dirty floors, and overflowing trashcans were present in resident use areas. The facility census was 40. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and service care to prevent possible urinary tract infections when staff failed to provide catheter (tube placed in the body to drain and collect urine from the bladder) care per standards of practice, failed to obtain an order for catheter care, and failed to complete catheter care per the care plan for one resident (Resident #2). The facility census was 40. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and follow an effective infection control program when staff failed to perform proper hand hygiene and prevent cross-contamination while performing peri-care for one resident (Resident #2) and when providing wound care to one resident (Resident #4). The facility census was 40. Review of the facility policy titled Standard Precautions Infection Control, dated 04/18/25, showed the following:-All staff are to assume that all residents are potentially infected or colonized with an organism that could be transmitted during providing resident care services. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to be administered in a manner that enables it to use its resources (facility's operating budget) effectively and efficiently when the facility failed to ensure all bills were paid in a timely manner to prevent credit holds and delays in maintenance of the fire and rescue system. The facility census was 44. Review showed the facility did not provide policy and procedure regarding bill pay.1. During an interview on 01/18/26, at 9:52 A.M., the Maintenance Director said the following:-The fire and safety system, including sprinklers, was serviced by Marmic Fire and Rescue;-The only current concern with the system is an air pressure leak; -Marmic provided inspection and maintenance services quarterly. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure a safe, functional, sanitary, and comfortable environment was provided for residents and staff when the facility failed to keep the walls in the kitchen free from discoloration, moisture, and fuzzy/powdery substance. The facility census was 44. 1. Observation and interview on 01/18/26, at 1:15 P.M., showed the following:-Upon entering the cleaning side of the kitchen and looking to the right there was black and green spotted discoloration was seen in the corner from the top of the sink area up to the ceiling. The texture appeared powdery;-DA H pulled back the splash guard behind the sink and black and green spotted discoloration was seen. The area also appeared wet;-DA H continued to pull back splash guards/protective paneling going further into the kitchen area near a window. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure resident representatives and physicians were notified of changes in condition in timely fashion when staff failed to document guardian and physician notification for one resident (Resident #3) who had a documented change in condition. The facility census was 44. Review of the facility's policy titled Notification of Changes, dated [DATE], showed the following information:-The facility must inform the resident, consult the resident's physician, and/or notify the resident's family member or legal representative when there is a change requiring notification;-Circumstances requiring notification include a significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health, mental, or psychosocial status; [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents who were unable to carry out their own activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting ) received the necessary services to maintain grooming when the facility failed to ensure showers were offered to one resident (Resident #2). The facility census was 44. Review of the facility policy titled Resident Showers, dated 06/10/25, showed the following information:-It is the practice of this facility to assist resident's with bathing to maintain proper hygiene, stimulate circulation, and help prevent skin issues in accordance with current standards of practice;-Residents will be provided showers in accordance with the resident's preferences, care plan, and safety needs, as well as the facility's scheduled bathing protocol. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from accidents when the facility failed to notify the resident's physician and family after a fall and failed to review and update the resident's care plan for one resident (Resident #2) who suffered a fall. The facility census was 44. Based on interview and record review, the facility failed to ensure residents were free from accidents when the facility failed to notify the resident's physician and family after a fall and failed to review and update the resident's care plan for one resident (Resident #2) who suffered a fall. The facility census was 44. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free of significant medication errors when the facility failed to have a chemotherapy medication (a powerful drug that kill fast-growing cancer cells by disrupting their ability to grow and divide) on hand for administration and failed to follow-up with the pharmacy and physician when the medication was not administered for one resident (Resident #1). The facility census was 44. Review of the facility policy titled Medication Errors. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program to control the fly population when multiple flies were present in and around four residents (Resident #1, Resident #2, Resident #3, Resident #4). The facility census was 49. Review of the facility's policy titled Pest Control Program, revised 06/15/25, showed the following:-It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents;-Facility will utilize a variety of methods in controlling certain seasonal pests, flies. These will involve indoor and outdoor methods that are deemed appropriate by the outside pest service and state and federal regulations.1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all allegations of possible abuse were reported immediately to facility management and within two hours to the state licensing agency (Department of Health and Senior Services-DHSS) when staff failed to report an allegation of employee to resident abuse until the following day for one resident (Resident #1). The facility census was 46. Review of the facility policy titled, Abuse Prevention, dated 10/21/22, showed the following: -The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, and staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitor, or any other individual; [...]

Inspectors wroteBased on interview and record review, the facility failed to document a timely and thorough investigation, to include interviews with multiple staff and other residents, and immediate steps taken to protect all residents during the investigation for an allegation of possible physical abuse involving one resident (Resident #1). The facility census was 46. Review of the facility policy titled, Abuse Prevention, dated 10/21/22, showed the following: -The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, and staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitor, or any other individual; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pharmacy services that included procedures for accurate administering and documentation of administration of all medications when staff failed to document administration of physician ordered medications for for six residents(Resident #1, #2, #3, #4, #7, and #10). The facility census was 52. Review of the facility policy titled, Administration Procedures for All Medications, revised August 2014, showed the following: -Purpose to administer medications in a safe and effective manner; -After administration of medication, return to the cart, replace the medication container, and document administration in the medication administration record (MAR), and controlled substance sign out record, if indicated; -Monitor for side effects or adverse drug reactions immediately after administration and throughout each shift; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was served at temperatures that were palatable and appetizing for three residents (Resident #1, Resident #8, and Resident #9) who often ate in their rooms. The facility census was 52. Review of the facility policy titled, Food Temperatures, undated, showed the following: -The temperature of all food items will be taken and properly recorded prior to service of each meal; -All hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 degrees Fahrenheit (F); -Cooking temperatures must be reached and maintained according to regulations, laws, and standardized recipes while cooking; -Hot food items may not fall below 135 degrees F after cooking; -All cold food items must be stored and served a temperature of 41 degrees F or below; [...]

Inspectors wroteBased on record review and interview, the facility failed to complete an admission Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff) in a timely manner for one residents (Resident #6). The facility census was 52. Review showed the facility did not provide a policy related to MDS assessments. 1. Review of Resident #6's face sheet showed the following: -admission date of 04/08/25; [...]

Inspectors wroteBased on record review and interview, the facility failed to complete significant change Minimum Data Sets (MDS - a federally mandated assessment instrument completed by facility staff) one resident (Resident #7) who was moved to the locked unit in the facility. The facility census was 52 Review showed the facility did not provide a policy related to MDS assessments. 1. Review of Resident #7's face sheet showed the following: -admission date of 10/25/22; [...]

Inspectors wroteBased on record review and interview, the facility failed to complete a discharge with return anticipated Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff) and a readmission MDS within seven days for one resident resident (Resident #5). The facility census was 52 Review showed the facility did not provide a policy related to MDS assessments. 1. Review of Resident #5's face sheet (a brief information sheet about the resident) showed the following: -admitted on [DATE]; -Diagnosis included: [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan for all residents when staff failed to complete a baseline care plan within 48 hours of admission of one resident (Resident #6). The facility census was 52. Review of the facility policy titled, Baseline Care Plan, dated April 2017, showed the following: -Development and implementation of a baseline care plan to deliver effective and person-centered care for the resident that meets professional standards of quality care within 48 hours of admission; -To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within 48 hours of the resident's admission; [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement accurate comprehensive care plans for all residents when staff failed to complete a comprehensive care plan for one resident (Resident #6) and when staff failed to care plan behaviors leading to one resident's (Resident #7) move to the locked unit. The facility census was 52. Review of the facility policy titled, Comprehensive Person-Centered Care Plans, dated April 2025, showed the following: -Development and implementation of a comprehensive person-centered care plan for each resident that is consistent with resident rights, which include measurable objectives and timeframes to meet the medical, nursing, mental and psychosocial needs that are identified through the comprehensive assessment; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility was administered in an effective and efficient manner to ensure the highest practical well-being of all residents when the facility failed to pay their bills in a timely manner for a generator that was being utilized resulting in the generator being removed. The facility census was 54. Review showed the facility did not provide a policy regarding timeliness of payments to companies providing services. 1. Observation on 04/02/25, at 9:30 A.M., showed the following: -A disconnected natural gas generator outside the facility on a concrete pad near the kitchen exterior wall; -No other connected or operational generator was observed on the facility grounds. Review of facility invoices for generator services showed the following: -An invoice, dated 04/07/25, with an amount due of $41,796.95; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure nurse aides (NA) completed their training, competencies, and testing in a timely manner when two NA's failed to complete a state approved certified nursing assistant (CNA) training program, competency evaluation, and certification test within four months of hire and continued to work providing direct care to residents. The facility census was 54. Review showed the facility did not provide a policy regarding NA training classes. 1. Review of the facility list of NA's currently employed at the facility, and working the floor as an NA, dated 04/02/25, showed the following: -NA I was hired as an NA on 09/02/24; -NA J was hired as a dietary staff on 03/23/24 and transitioned to NA on 09/23/24. Review of NA I's personnel file showed staff did not have documentation of a CNA certification. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate incontinent care (support and management strategies needed to assist individuals who experience the involuntary loss of bladder or bowel control) was provided when staff failed to check and change one resident (Resident #1) who was visibly incontinent of urine. The facility had a census of 54. Review of the facility provided policy titled Incontinent Care, dated 07/21/22, showed the facility staff will provide incontinent care as directed in the plan of care. 1. Review of Resident #1's face sheet showed the following information: -admission date of 12/26/22; [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain a functional environment for all residents, staff, and the public when staff failed to maintian the front entrance door power American Disabilities Act (ADA) button. The facility census was 50. Review showed the facility did not provide a policy regarding maintenance of the front door. 1. Observation on 11/25/24, at 9:25 A.M., of the front entrance door showed the following: -An ADA push button located to the left of the front entrance door; -The power button located at the door open mechanism was illuminated and in the Auto-On position; -The door did not open when the ADA button was pressed. During an interview on 11/25/24, at 9:22 A.M., the Maintenance Director said the following: -He has worked at the facility for one month; -The ADA button for the front door has not worked since he started; [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure all residents maintained acceptable parameters of nutrition unless unavoidable when staff failed to identify weight loss risk timely and failed to care plan current or new weight loss interventions for one resident (Resident #1) out of a sample of five residents. The facility census was 50. Review of the facility policy titled, Weight Assessment and Intervention, revised September 2008, showed the following: -The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents; -The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure consistent and sufficient Registered Nurse (RN) and Director of Nursing (DON) hours to allow the DON to complete the duties of DON when the DON frequently had to work the charge nurse or a certified nurse aide (CNA). The facility census was 50. Review of the facility's job description titled, Director of Nursing Services, undated, showed the following: -The primary purpose of the position was to plan, organize, develop, and direct the overall operation of the nursing service department in accordance with current federal, state, and local standards, guidelines, and regulations that govern the facility and as may be directed by the Administrator or the Medical Director to ensure that the highest degree of quality care is maintained at all times; [...]

Inspectors wroteBased on interview and record review, the facility staff failed to employ a qualified dietary manager for food and nutrition services with accredited education in food service management. The facility census was 50. Review of the facility's policy titled, Director of Food and Nutrition Services, undated, showed the following: -The Director of Food and Nutrition Services (DFNS) will be responsible for all aspects of the food and nutrition services department including but not limited to food safety, staff safety, cost management, and meeting nutritional needs of patients/residents served; -The DFNS will be hired by corporate staff, the Administrator, or by the immediate supervisor of the position as deemed appropriate by the facility; -The DFNS will be qualified according to the position's job description and guidelines put forth by the agency that regulates the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility was administered in an effective and efficient manner to ensure the highest practical well-being of all residents when the facility failed to pay their bills in a timely manner. The facility census was 48. 1. Review of the facility's laboratory service invoices showed the following: -An invoice, dated 07/16/24, with an amount due of $446.46; -An invoice, dated 07/31/24, with an amount due of $3,063.46; -An invoice, dated 08/22/24, with an amount due of $3,497.40; -An invoice, dated 08/26/24, with an amount due of $327.46; -An invoice, dated 09/17/24, with an amount due of $918.94; -An invoice, dated 09/23/24, with an amount due of $2,684.94; -The invoice total due was $10,938.66. Review of a statement to the facility from the laboratory services company, dated 12/06/24, showed the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed maintain a complete and effective infection control program when the facility failed to have a thorough program for the prevention of the growth of the Legionella bacteria (a bacteria which causes a respiratory disease when breathing in small droplets of water in the air that contain Legionella. A Legionella infection is also called Legionnaires' Disease. It can become a health concern when it grows and spreads in human-made water systems.) in the facility water supply or where moist conditions existed. The facility also failed to perform hand hygiene per standards of practice during medication passes involving multiple residents. The facility census was 50. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement an effective and complete antibiotic stewardship program when staff failed to track residents on antibiotics for various infections in the facility by not completing a current and ongoing antibiotic log of residents with active infections. This failure could potentially place all residents at risk of infection. The facility census was 50. Review of a facility policy titled, Antibiotic Stewardship - Order for Antibiotics, dated December 2016, showed the following: -Antibiotics will be prescribed and administered to residents under the general guidance of the Antibiotic Stewardship Program; -Prescribers will provide the drug name, dose, frequency, duration, route, and indication for antibiotic orders; -The prescriber will assess the resident within 24 hours of a telephone antibiotic order; [...]

Inspectors wrote2. Review of Resident #6's face sheet showed the following information: -admission date of 07/02/24; -Diagnoses included type two diabetes, low blood pressure, peripheral vascular disease (PVD- a circulatory condition in which narrowed blood vessels reduce blood flow to limbs), and heart failure. Review of the resident's annual MDS, dated [DATE], showed the following information: -At risk for developing pressure ulcers; -Has stage one or greater pressure ulcer; -Two stage 2 pressure ulcers present at admission. Reviewoftheresidentscareplan lastrevisedon08/15/24, showedthefollowinginformation -CompleteBradenscaleuponadmission; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care per standards of practice when staff failed to ensure staff changed oxygen equipment per professional standards for two residents (Resident #46 and #36) and failed to accurately document oxygen orders and care plan the use of oxygen for one resident (Resident # 36) out of a sample of 20 residents selected for review. The facility had a census of 50. Review showed the facility did not provide a policy regarding oxygen administration. 1. Review of Resident #46's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 06/12/24; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide effective pain management for all residents when staff failed to administer pain medications as ordered for two residents (Resident #252 and #36) and when staff failed to document an order for pain medication for one resident (Resident #36). A sample of 20 residents was reviewed in the facility with a census of 50. Review of the facility's policy titled Pain Assessment and Management, revised in March 2015, showed the following information: -Pain management was defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of 5% or less when facility staff made five medication errors out of 39 opportunities (12.82% error rate) affecting three residents (Resident #9, #34, and #49). The facility census was 50. Review of the facility's policy titled Medication Administration, undated, showed the five rights to be followed were the right patient, right drug, right dose, right time and right route; 1. Review of Resident #9's face sheet (a document that gives a resident's information at a quick glance) showed the following information: -admission date of 11/28/22; -Diagnoses included diabetes mellitus (chronic, metabolic disease characterized by elevated levels blood glucose) and congestive heart failure (CHF - chronic condition in which the heart doesn't pump blood as well as it should). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all medications were stored and labeled in accordance with standards of practice when staff failed to store controlled substances under two locks for two residents (Resident #1 and Resident #39) and when medication carts were left unlocked when unattended. The facility census was 50. Review of the facility's Storage of Medication Policy, undated, showed the following: -The facility shall store all drugs and biological's in a safe, secure, and orderly manner; -The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs and preferences when they failed to have hydration accessible for one resident (Resident #20) out of 20 sampled residents. The facility census was 50. Review of the facility's policy titled Resident Hydration and Prevention of Dehydration, revised October 2011, showed the following information: -The facility will endeavor to provide adequate hydration and to prevent and treat dehydration; -Nurses' Aides will provide and encourage intake of bedside, snack, and meal fluids, on a daily and routine basis as a part of daily care. -If potential inadequate intake or signs and symptoms of dehydration are observed, intake and output monitoring will be initiated and incorporated into the care plan. [...]

Inspectors wroteBased on interview and record review, the facility failed to administer the required Preadmission Screening and Resident Review (PASARR) Screening (Level 1) to identify residents with a mental disability (MD), intellectual disability (ID) or a related condition for one resident (Resident #30) prior to admission to the facility. The facility census was 50. Review of a facility policy titled admission Criteria, dated December 2016, showed the following: -Nursing and medical needs of individuals with mental disorders will be determined by coordination with Medicaid PASARR program to the extent practicable; -Potential residents with mental disorders will only be admitted if the state mental health agency has determined (through the preadmission screening program) that the resident has a physical or mental condition that requires the level of service provided by the facility. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services to meet the needs of each resident when facility staff documented ordered medication could not be administered on multiple dates due to not being available on-site for one resident (Resident #15). The facility census was 50. Review of the facility's policy Documentation of Medication Administration, revised April 2007, showed the following: -The facility shall maintain a medication administration record to document all medications administered; -A nurse or certified medication aide (where applicable) shall document all medications administered to each resident on the resident's Medication Administration Record (MAR); -Administration of medication must be documented immediately after (never before) it is given. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all residents were free of significant medication errors when staff failed to administer warfarin sodium (blood thinner that be used to treat and prevent blood clots) per the physician's order and failed to notify nurse management or the physician of the missed doses for one resident (Resident #152). The facility census was 50. Review of the facility's policy Documentation of Medication Administration, revised April 2007, showed the following: -The facility shall maintain a Medication Administration Record (MAR) to document all medications administered; -A nurse or certified medication aide, where applicable, shall document all medications administered to each resident on the resident's MAR; -Administration of medication must be documented immediately after, never before, it is given; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain complete medical records for all residents when staff failed to document full details and notifications related to two residents (Resident #41 and #46) who transferred to the hospital and later returned to the facility. The facility census was 50. Review of the facility's policy titled Charting and Documentation, revised April 2008, showed the following: -All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record; -All incidents, accidents, or changes in the resident's condition must be recorded; -Documentation of procedures and treatments shall include care-specific details and shall include at a minimum the date and time the procedure/treatment was provided; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from significant medication errors when the facility failed to document transcribe physician's orders accurately for one resident's (Resident #1) antipsychotic medication resulting in the resident receiving an incorrect dosages of medication. The facility had a census of 52. Review of a facility policy titled, admission Assessment and Follow Up: Role of the Nurse, not dated, showed the following: -Staff are to reconcile the list of medications from the medication history, admitting orders, previous medication administration records if available, and discharge summary from the previous institution; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have sufficient nursing staff to meet the needs of all the residents in a timely fashion and to provide showers in a timely fashion to four residents (Residents #3, #5, #16, and #37). The facility census was 49. 1. During a resident group meeting on 12/7/22, at 10:51 A.M., residents said the following; -Weekends are really bad regarding staffing with a very skeleton crew, very slow at getting to the lights and nurses passing medications; -One resident said the facility is short-handed during the day, but it was especially bad at night for the past nine months to a year. Often there was only one staff in the memory care unit during the night and one nurse acted as both nurse and aide for the rest of the facility; -Resident #40 is supposed to use a walker, but requires someone to be stand-by assistance. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide palatable and appeasing food to all residents. The facility had a census of 49. Record review of the facility policy, titled Menus, revised 2008, showed the following: -Menus shall meet the nutritional needs of residents, be prepared in advance, be followed, and meeting the needs in accordance with the recommended dietary allowances of the Food and Nutrition Board; -Menus and available snacks shall be adjusted to meet individual caloric and nutrient-intake needs of the resident; -The dietitian will review and approve all menus; -Deviations from menus that have already been posted will be noted and recorded noting such changes; -Menus will provide a variety of foods from the basic daily food groups and will indicate standard portions at each meal; -Menus will be varied for the same day of consecutive weeks; [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to protect food while stored per professional standards food contact surfaces (dishes) were stacked wet instead of air dried, dented cans were stored were no separated to prevent use, and when staff failed to date, label, or seal stored food after opening. The facility census was 48. 1. Record review of the facility policy titled Food Receiving and Storage, revised the 2014, showed the following information: -When food is delivered to the facility it will be inspected for safe transport and quality before being accepted; -Dry foods that are stored in bins will be removed from original packaging, labeled and dated ('use by date); -Such foods will be rotated using a first in-first out system; -Any other opened containers must be dated and sealed or covered during storage. [...]

Inspectors wroteBased on record review and interview, the facility failed to maintain an effective infection control program for all residents when the facility failed to have a program in place for the prevention of the growth of Legionella bacteria (a bacteria which causes a respiratory disease when breathing in small droplets of water in the air that contain Legionella. It can become a health concern when it grows and spreads in human-made water systems) in the facility water supply or where moist conditions existed. The facility staff also failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to use appropriate hand hygiene while completing medication administration for two residents (Resident #3 and #8). The facility census was 49. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a criminal background check (CBC) and Employee Disqualification List (EDL - a state listing of individuals who have been determined to have: abused or neglected a resident, patient, client, or consumer; misappropriated funds or property belonging to a resident, patient, client, or consumer; or falsified documentation verifying delivery of services to an in-home services client or consumer) check for one staff (Certified Nurse Aide (CNA) S) and failed to check the Nurse Aide (NA) Registry for two staff (CNA D and Registered Nurse (RN) S) to ensure they did not have prior criminal offenses or a Federal Indicator (a marker given to a potential employee who has committed abuse, neglect, or misappropriation of property against residents) prohibiting them from working in a certified facility. The facility's census was 49. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to the hospital, including the reason for the transfer, for three residents (Residents #44, #200 and #203). The facility census was 49. Record review showed the facility did not have a written policy and procedure pertaining to written notices to residents and/or their representative when a resident is transferred to the hospital. 1. Record review of Resident #44's face sheet showed an admission date of 9/26/2022. Record review of resident's nurses' notes showed the following information: -On 11/24/2022, at 10:41 A.M., the resident had a temperature between 100 and 103.5 degrees Fahrenheit (F - 98.7 degrees F is considered normal) that morning. Staff applied cool compresses under the arms and groin area. [...]

Inspectors wroteBased on interview and record review, the facility failed to give written information to the resident and/or resident's representative regarding the facility's bed hold policy for five residents (Residents #4, #44, #48, #200, and #203) who were transferred out to the hospital. The facility census was 49. Record review showed the facility did not have a written policy pertaining to the issuance of written information to the resident and/or resident's representative of the bed hold policy when a resident is transferred out of the hospital. Record review of a facility form entitled Bed-Hold Notice showed the following information: -Staff should fill in blanks for: resident name; facility name; maximum number of days for no cost bed hold while hospitalized or during therapeutic leave or vacation (if facility is paid by Medicaid); and facility contact information; [...]

Inspectors wroteBased on record review and interview, facility staff failed to complete a quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff) assessment for eight residents (Residents #7, #9, #16, #27, #29, #32, #36, and #38) not less than every three months (92 days). The facility had a census of 49. Record review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, Chapter 2, Assessments for the RAI, showed the following information: -The quarterly assessment is an Omnibus Budget Reconciliation Act of 1987 (OBRA) non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type; [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to develop and implement a care plan related to Resident #3's urinary catheter care and shower needs. The facility failed to develop and implement a care plan related to Resident #16's ostomy (allows bodily waste to pass through a surgically created area on the abdomen into a 'pouch' or 'ostomy bag' on the outside of the body) medical needs. The facility failed to update Resident #42's care plan to reflect the findings of the resident's assessment for safety while smoking. The facility census was 49. Record review showed the facility did not provide a policy related to care plans. 1. Record review of Resident #3's face sheet (gives basic profile information) showed the following information: -admission date of 7/26/22; [...]

Inspectors wroteBased on record review and interview, the facility failed to develop and implement an effective system to ensure a resident's choice of code status (the type of emergent treatment a person would or would not receive if their heart or breathing were to stop) was readily accessible to staff and documented consistently throughout the medical record for four residents (Residents #4, #5, #10, and #200). The facility census was 49. Record review of the facility policy, titled Advance Directives, dated [DATE], showed the following information: -Upon admission, the resident will be provided with written information concerning the right to refuse of accept medical or surgical treatment and to formulate and advance directive if he or she chooses to do so; [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to store refrigerated medications at the manufacture's recommended temperatures and failed to have a system in place to monitor and adjust the temperature as needed. The facility census was 49. Record review of the facility's policy titled Storage of Medications, dated April 2007, showed the following information: -The facility shall store all drugs and biologicals in a safe, secure, and orderly manner; -Medications requiring refrigeration must be stored in a refrigerator located in the medication room or other secured location. Medication must be stored separately from food and must be labeled accordingly. 1. Observation on 12/12/22, at 11:15 A.M., of the medication refrigerator in the medication room located behind the nurse desk showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote and facilitate self-determination when staff failed to honor the preference of one resident (Resident #16) to take his/her own smoking supplies off of facility property when signing out. The facility failed to promote self-determination when the facility presented a new facility policy showing the resident (Resident #3) could no longer use electronic cigarette devices and took his/her personal property away, resulting in the resident purchasing cigarettes in order to smoke. The facility census was 49. Record review of the facility provided, undated, policy titled, Smoking Policy, showed the following in information: -It is the policy of the facility to provide employees with as near a smoke-free environment as possible and to ensure safe smoking practices for those who smoke; [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide clean bed linens that were in good condition for four residents (Residents #15 and #18). The facility census was 49. Record review showed the facility did not provide a policy related to resident bed sheets. Record review of the facility's Shower Schedule, dated 10/19/2022, showed shower days are also bed strips and bed cleaning days. 1. Record review of Resident #15's face sheet showed the following: -admission date of 7/12/19; -Diagnoses included pigmentary retinal dystrophy (major cause of severe progressive vision loss), asthma (airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breathe) , anxiety disorder,and type 2 diabetes mellitus (impairment in the way the body regulates and uses sugar (glucose) as a fuel). [...]

Inspectors wroteBased on record review and interviews, the facility failed to complete and electronically transmit a discharge Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff) for one resident (Resident #39). The facility census was 49. Record review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, Chapter 2, Assessments for the RAI, showed the following information: -The discharge assessment is an Omnibus Budget Reconciliation Act of 1987 (OBRA) non-comprehensive resident assessment; -The discharge assessment must be completed no later than 14 calendar days after the discharge; -The MDS must be transmitted no later than 14 calendar days after the MDS completion date. 1. Record review of Resident #39 MDS submitted reports showed the following information: -admitted to the facility 7/16/2022; [...]

Inspectors wroteBased on record review and interview, the facility failed to complete a baseline care plan within 48 hours of admission for one resident (Resident #203) and failed to document reviewing or providing a copy of a baseline care plan to the resident and/or resident representative. The facility census was 49. Record review showed the facility did not provide a policy pertaining to baseline care plans. 1. Record review of Resident #203's facility face sheet (a document that gives a resident's information at a quick glance) showed the following information: -admission date of 12/1/22; [...]

Inspectors wroteBased on observation and interview, facility staff failed to post required nurse staffing information daily. The facility census was 49. 1. Observation on 12/06/22, at 10:52 A.M., showed the nurse staffing hours posted on a board behind the main nursing station. The staff posting was dated 11/22/22. Observation on 12/09/22, at 10:01 A.M., showed the nurse staffing hours posted on a board behind the main nursing station. The staff posting was dated 12/8/22. Observation on 12/11/22, at 7:30 P.M., showed the nurse staffing hours posted on a board behind the main nursing station. The staff posting was dated 12/8/22. Observation on 12/12/22, at 11:10 A.M., showed the nurse staffing hours posted on a board behind the main nursing station. The posting was dated 12/8/22. Observation on 12/13/22, at 1:30 P.M., showed the nurse staffing hours posted on a board behind the main nursing station. [...]

Inspectors wroteBased on observation and interview, facility staff failed to ensure every hose that extended below the flood plain had a backflow preventer (an anti-siphon device used to keep toxins from backing up into the potable water supply). This affected both of the shower rooms. The facility census was 46. 1. Observation on 11/5/19, starting at 10:30 A.M., showed: - The shower hose in the hospice/unit shower room extended to the floor and did not have a backflow preventer. - Both shower hoses in the main shower room extended to the floor and did not have a backflow preventer. During an interview on 11/5/19, at 3:45 P.M., the Maintenance Supervisor said he did not realize all hoses that extended below the flood plain were required to have a backflow preventer.

Inspectors wroteBased on interview and record review, the facility failed to maintain a surety bond sufficient to ensure protection of resident funds. The facility's census was 46. 1. Record review of the facility's documented surety bond showed the facility had an approved bond for $20,000.00. Record review of the facility's reconciled bank statements from October 2018 through September 2019, showed an average monthly balance of $23,000.00. Based on this amount, the facility needed a bond of at least $34,000.00 (one and a half times the average monthly balance). During an interview on 11/8/19, at 9:17 A.M., the business office/facility bookkeeper said after she received the facility's monthly bank statement she scanned and sent it to the corporate office. Corporate staff added the interest to each resident fund account. Facility funds and resident funds were kept in separate accounts. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN, form CMS-10055) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for one resident (Resident #37) who remained in the facility after discharge from Medicare Part A services. The facility census was 46. Record review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C -09-20), dated 1/9/09, showed the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide restorative nursing services to maintain or improve one resident's (Resident #41) functional status as directed by therapy out of a selected sample of 16 residents. The facility census was 46. Record review of the facility's Restorative Nursing Services policy, updated July 2017, included the following information: -Residents will receive restorative nursing care as needed to help promote optimal safety and independence. Record review of the facility's Resident Mobility and Range of Motion policy, updated July 2017, included the following information: -Residents will not experience an avoidable reduction in range of motion (ROM); -Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #35), with a history of acute renal failure and urosepsis (sepsis caused by an infection of the urinary tract), received necessary monitoring after the physician discontinued his/her indwelling urinary catheter (a sterile tube inserted into the bladder to drain urine)and failed to follow physician's orders for recatheterization when the resident had no urinary output, resulting in severe urinary retention. A sample of 16 residents were selected for review in a facility with a census of 46. Record review of the facility's Foley (indwelling) Catheter Removal policy, revised on October 2010, included the following information: -The purpose of this procedure is to provide guidelines for the approved method of removing an Foley catheter; [...]