Carnegie Village Rehabilitation & Health Care Cent

Inspectors wroteBased on observation, interview and record review, the facility failed to store food appropriately in the kitchen. This practice has the potential to affect all residents, visitors, and employees who eat at the facility. The facility census was 68 residents. Review of the facility's undated policy titled Food Storage (Dry, refrigerated, and frozen) showed:-All food items must be labeled.-The labels must include the name of the food and the date by which it should be sold, consumed, or discarded.1. Observation on 7/17/25 at 9:14 A.M. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain commodes in the following resident rooms (rooms 107, 100, 167, 162, 140, 132, and 124) free of numerous indentations and scratches which rendered the commodes not easily cleanable. This practice potentially affected 7 residents who resided in those rooms. The facility census was 68 residents.1. Observation on 7/21/25 with the Maintenance Director showed:-At 1:51 P.M. there were numerous indentations on the commode seat in resident room [ROOM NUMBER].-At 1:59 P.M. there were numerous indentations on the commode seat in resident room [ROOM NUMBER].-At 2:29 P.M. there were numerous indentations on commode seat in resident room [ROOM NUMBER].-At 2:41 P.M. there were numerous indentations on the commode seat in resident room [ROOM NUMBER]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen and respiratory equipment was kept in a sanitary condition when not in use for three sampled residents (Resident #7, #8, and #33) and failed to ensure one sampled resident's (Resident #33) oxygen was at the correct setting out of 17 sampled residents. The facility census was 68 residents. An oxygen policy was requested and not provided by the time of exit. 1. Review of Resident #7's face sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of chronic respiratory failure with Hypoxia (when the lungs cannot properly exchange gases). Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning) dated 6/20/25 showed: [...]

Inspectors wroteBased on interview and record review the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases when the facility failed to follow their policy to provide Tuberculosis (TB-a communicable disease that affects the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) testing for four employees (Employees E, G, J, and K) out of ten employees sampled for TB screening and for one sampled resident (Resident #52) out of five residents sampled for TB screening; failed to ensure one sampled resident's (Resident #33) foley catheter bag (a flexible tube inserted into the bladder to drain urine) was kept in a sanitary condition by allowing the foley bag to touch the floor; [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the audible signal from the call light at the west and east nurse's stations, was loud enough to be heard above ambient (surrounding on all sides) noise such as televisions which were on at the adjacent day rooms and in the adjacent resident rooms and conversations which happened at the nurse's stations. This practice potentially affected 10 residents in rooms where the call lights were activated. The facility census was 68 residents.1 1. Observation on 7/22/25 from 2:55 P.M. to 3:16 P.M. showed:-The call lights from resident rooms 116, 208, 200, 201, and 205 were activated.-There were two quick sounding beeps.-30 seconds went by and it beeped twice again.-The room number showed up on the wall device where the sound came out.-The sound repeated every 30 seconds in the same soft tone at the [NAME] nurse's station. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the lids of the dumpsters were closed on 7/22/25 and 7/23/25. The facility census was 68 residents.1. Observation on 7/22/24 at 11:09 A.M., and 3:48 P.M., showed the dumpsters in the dumpster area had the lids open. Observation on 7/23/25 at 11:46 A.M. and 12:49 P.M. showed the dumpsters in the dumpster area had the lids open. During an interview on 7/23/25 at 12:43 P.M., the Dietary Manager (DM) said:-He/She had to constantly remind personnel form other departments within the facility and personnel in the dietary department to keep the lids closed.-He/She expected any staff from any department to close the lids once they dumped trash in the dumpsters. During an interview on 7/23/25 at 2:31 P.M., the Administrator said facility staff should shut the lid of the dumpsters.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision to prevent accidents for one sampled resident (Resident #1). Licensed Practical Nurse (LPN) A failed to visualize the resident when performing the required midnight census safety rounds and Certified Nursing Assistant (CNA) A failed to visualize the resident when doing two-hour nightly rounds. As a result, the resident self exited into the facility courtyard after dark, without staff awareness and fell from his/her wheelchair out of six sampled residents. The facility census was 62 residents. On 6/3/25, the facility Administration was notified of the past noncompliance which occurred on 5/31/25. Facility staff had subsequently been educated on hourly checks to courtyard, abuse, neglect, and two-hour rounding by CNAs. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent the misappropriation of 30 tablets of 2 milligrams (mg) Hydrocodone (an opioid pain medication used to treat moderate to severe pain) belonging to one sampled resident (Resident #2) out of four sampled residents. The facility census was 66 residents. The Administrator was notified on 9/18/24 of Past Non-Compliance which occurred on 9/3/24. An all nursing staff in-service was completed on drug diversion and working under the influence of drugs/alcohol by 9/3/24. The resident's missing medications were replaced and paid for by the facility. The deficiency was corrected 9/3/24. Review of the facility's Controlled Substance Policy revised 5/23 showed: -Controlled substances were subject to special handling, storage, disposal and record-keeping requirements. [...]

Inspectors wroteBased on interview and record review, the facility failed to contact Emergency Medical Services (EMS), check code status, initiate and provide cardiopulmonary resuscitation (CPR- an emergency procedure that is performed when a person's heartbeat or breathing has stopped) for one sampled resident (Resident #1) who was a full code status. On [DATE], Registered Nurse (RN) A and Agency Licensed Practical (LPN) A found the resident without spontaneous respirations and pulse. RN A and LPN A did not check the resident's code status, initiate CPR, or contact EMS. As a result the resident died. The facility census was 66. The Regional RN was notified on [DATE] at 12:03 P.M., of the Immediate Jeopardy (IJ) Past Non-Compliance which occurred on [DATE]. On [DATE], the Administrator became aware of the violation of the facility's CPR policy. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide transportation to two scheduled follow up appointments for one sampled resident (Resident #2) out of four sampled residents. The facility census was 68 residents. A policy for outside appointments was requested from the facility's Director of Nursing (DON). He/she reported the facility had no policies related to outside appointments for residents. 1. Review of Resident #2's admission Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning), dated 9/25/23, showed: -The resident scored a 05 on the Brief Interview for Mental Status (BIMS), an assessment tool that shows a score between 3 of 15 which shows the resident's mental status. This tool helps determine the resident's attention, orientation and ability to register and recall new information. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control to prevent cross contamination when staff failed to sanitize the access point of insulin pens prior to attaching the needle for two supplemental residents (Residents #26 and #38); to ensure infection control, including hand hygiene during wound dressing change for one sampled resident (Resident #46); to provide urinary catheter (a small tube inserted into the bladder to drain urine) care in a manner to prevent urinary tract infection and to ensure infection control practices were implemented to prevent cross contamination during perineal care on one sampled resident (Resident #32); [...]

Inspectors wroteBased on interview and record review, the facility failed to have parameters listed in the medication orders for any medication containing Acetaminophen (an over-the-counter pain medication) or three sampled residents (Resident #12, Resident #17, and Resident #25) out of 18 sampled residents. The facility census was 70 residents. Review of the facility's undated Medication Administration-Oral checklist did not include parameters for medications. Review of the undated product information insert guide for Acetaminophen showed directions not to administer more than 3 grams (gm - 1 gm is equal to 1000 milligrams (mg)) in a 24 hour period. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain a Preadmission Screening and Resident Review (PASARR - a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) for one sampled resident (Resident #49) out of 18 sampled residents. The facility census was 70 residents. A policy for PASARR was requested from the facility and not provided. 1. Review of Resident #49's admission Record showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Senile degeneration of the brain (the mental deterioration (loss of intellectual ability) that is associated with or the characteristics of old age). -Generalized anxiety disorder (a condition of excessive worry about everyday issues and situations). -Cognitive communication deficit (difficulty with thinking and how someone uses language). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician orders for a Low Air Loss Mattress (LAL- an air mattress covered with tiny holes which are designed to let out air very slowly which helps keep the skin dry and [NAME] away any moisture), to follow physician orders to apply topical medication to the resident's skin as needed for moisture and redness and to apply protective barrier cream after resident incontinent episodes with moisture associated skin breakdown per professional standards of practice for one sampled resident (Resident #32) out of 18 sampled residents. The facility census was 70 residents. A policy and procedure for physician orders, and use of barrier cream was requested and was not provided prior to exit from the facility. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services to prevent and heel pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) for two sampled residents (Resident #37 and #67) with pressure ulcers out of 18 sampled residents. The facility census was 70 residents. Review of www.medline.com/strategies/skin-health/evidence-based-best-practices-heels-npiap-guidelines-help-prevent-pressure-injuries/ dated July 2020 showed: -For residents at risk of heel pressure injuries (pressure ulcers) and/or with Stage I (Intact skin with non-blanchable redness of a localized area usually over a bony prominence) or Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure reconciliation of a Schedule II (a drug having medical usefulness, but also a high potential for abuse) narcotic drug (an opioid - a medication which acts on the central nervous system (CNS) to relieve pain) for one sampled resident (Resident #27) out of 20 sampled residents. The resident's Medication Administration Record (MAR) showed blank spaces which were discrepancies from the resident's Controlled Drug Receipt/Record/Disposition Form. The facility census was 70 residents. On 9/14/23, the Administrator was notified of the past noncompliance which took place over a period of time to include 8/29/23 through 9/8/23. Narcotic documentation discrepancies were discovered during audits by the Corporate Nurse Manager. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication administration error rate was less than five percent (5%) when staff failed to prime then insulin pen needle prior to administering insulin to two sampled residents (Residents #26 and #38) out of two sampled residents for insulin administration for an error rate of 9.68%. The facility census was 70 residents. A policy for insulin administration was requested and not received at the time of exit. Review of the product information guide for Lantus Insulin (a long acting insulin) updated 6/22 showed: -Do a safety test before each injection to make sure the pen and needle are working properly and the proper dose is administered. -Prime the needle with 2 units of insulin, if insulin comes out of the top of the needle, the pen and needle are working properly. [...]

Inspectors wrote13. Record review of the facility's undated job description, Certified Nursing Assistant: showed: -The Staff was to wash hands before entering and after leaving an isolation room/area. -The Staff was to follow established procedures in the use and disposal of personal protective equipment. Observation of the Transitional Unit (unit where residents were kept when they returned from the hospital to ensure they did not have COVID-19) on 1/14/22 at 1:45 P.M., showed: -Certified Nurses Assistant (CNA) H came out of the Transitional unit through the zippered tarps without closing the tarps. -He/she walked 20 feet into the non-COVID-19 unit with full PPE on. -He/she was pushing the meal cart down the hallway. -He/she took off the isolation gown and gloves waded them up and stuck them in a hall handrail. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two wells of Steam Table A in the kitchen operated properly to ensure suitable holding temperatures of 135 degrees Fahrenheit (°F) or higher, of food placed in two of three wells of Stem Table A, and to ensure the numbers of the dials on Steam table B, were visible to dietary staff. This practice potentially affected 72 out of 73 residents who ate food from the kitchen. The facility census was 73 residents. 1. Record review of the Maintenance log dated 11/23/21, 12/6/21, and 12/7/21, showed two wells of the Steam Table A have not been working. Record review of Maintenance Log dated 11/25/21, showed parts were ordered to fix Steam Table A. Record review of the Maintenance Log dated 1/7/22 showed two wells of Steam Table A that were also not operating properly on 12/7/21. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all the necessary equipment was available for the facility to comply with the both the audible and visual requirements of the exception to state regulation 19 Code of State Regulations (CSR) 30-85.012 (124) and for facility staff to use, to adequately answer call lights. This practice potentially affected all residents. The facility census was 73 residents. 1. Record review of the facility's exception certificate, dated 5/31/18, showed: -The operator will ensure the wireless nurse call system is fully operational twenty-four (24) hours per day, seven (7) days a week. -The operator will maintain, at a minimum and in accordance with the manufacturer's recommendations, all the features of the wireless call system. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician's orders for wound care for a resident's pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) was completed as prescribed for three sampled residents (Residents #33, #36 and #67) out of 19 sampled residents. The facility census was 73 residents. Record review of the facility's Pressure Ulcer/Pressure Injury Prevention policy revised on 3/2021 did not address documentation of wound care treatments. 1. Record review of Resident #36's Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE]. Record review of the resident's Care Plan dated 11/29/21 showed: -He/She was admitted to the facility with pressure ulcers. [...]

Inspectors wroteBased on observation, and interview, the facility failed to ensure staff were awake and assisting residents during their shift when staff were found sitting in chairs wrapped in blankets with one staff slumped over in the chair with his/her eyes closed and mouths hanging open. The facility census was 73 residents. 1. Observation of the rehabilitation and transitional units on 1/13/22 at 5:00 A.M. showed: -Three high back chairs at the end of the hall out of facility camera range. -Agency Certified Nursing Assistant (CNA) K and Agency CNA L were each sitting in a high back chair wrapped up in blankets with their eyes opened. -CNA M was sitting in the third chair, was wrapped up in a blanket, slumped over in the chair with his/her eyes closed and mouth hanging open sleeping. -One Agency Registered Nurse (RN) working on the unit. [...]

Inspectors wroteBased on interview and record review, the facility failed to post staffing information in a location that was easily accessible to residents on the Long Term Care (LTC) and Rehabilitation units of the facility and to ensure staffing data was posted for visitors that consistently included the facility name, daily census, and the actual hours worked per shift for each of the three categories of nursing employees: Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs)/Certified Medication Technicians (CMTs) directly responsible for resident care. The facility census was 73 residents. Record review of the facility's Posting Direct Care Daily Staffing Numbers policy, revised 2/2021, showed the facility will post the staffing on a daily basis at the beginning of each shift showing: -The date and daily census. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain and follow-up on medication regimen reviews (MRR) for three sampled residents (Resident #7, #11, and #21) out of 19 sampled residents. The facility census was 73 residents. Record review of the facility's undated policy titled Distribution of Medication Regimen Review report showed: -The consultant pharmacist would report any recommendations of apparent irregularities resulting from the medication regimen review report form or in electronic record keeping system. -Each recommendation must be acted upon. -The report form will be used by the consultant pharmacist to communicate findings of the monthly pharmaceutical care consultation. -The policy did not specify any time frames for responses and actions or steps that must be taken when an irregularity requires urgent action. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an order signed by the resident's physician was transcribed to the resident's Physician's Order Sheet (POS) and Medication Administration Record (MAR) resulting in staff administering a medication which had been discontinued for one sampled resident (Resident #11); to monitor blood sugars (the concentration of glucose in the blood) and administer Insulin (a hormone that lowers the level of glucose (a type of sugar) in the blood) as ordered for two sampled residents (Resident #49 and #53) out of 19 sampled residents. The facility census was 73 residents. Record review of the facility's undated Distribution of Medication Regimen Review (MRR) Report showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an unattended medication cart was locked and a loose pill was not left on the floor. The facility census was 73 residents. Record review of the facility's Medication Storage in the Facility policy dated [DATE] showed: -Medication carts and medications supplies were to be locked and attended by authorized personnel or locked. -Medications that were not stored within secure closures shall be removed from inventory and disposed of according to drug disposal procedures. 1. Observation on [DATE] from 9:03 A.M. to 10:41 A.M. showed: -9:03 A.M. to 9:58 A.M., three medication carts at the end of the hall near the nurse's station were unlocked and unattended. One medication cart had a resident's intravenous (IV) bag of medication on top of the cart unattended. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain corn and green beans at a temperature of 135 degrees Fahrenheit (°F) at the steam table, during the lunch meal on 1/10/22; to maintain the temperature of the macaroni salad at or below a temperature of 41 °F during the lunch meal on 1/10/22; to maintain the temperature of bacon at a temperature of 135 °F on the steam table during the breakfast meal on 1/12/22. This practice potentially affected at least 72 residents who at food from the kitchen during those meals. The facility census was 73 residents. 1. Record review of the maintenance log showed the steam table has not been working since December 2021, two wells of steam table not working. Observations during the lunch meal preparation on 1/10/22 from 10:23 A.M. through 1:00 P.M., showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the timely delivery of breakfast and lunch meals to eleven residents (Residents #65, #5, #53, #15, #318, #69, #56, #22, #28, #38 and #35) on 1/10/22 and on 1/12/22; and failed to ensure the meal ticket system worked properly to facilitate meal ticket orders. The facility census was 73 residents. 1. Record review of the facility's undated meal schedule showed meal pass times of 8:00 A.M. for breakfast and 12:00 P.M. for lunch. 2. Observation on 1/10/22 at 9:53 A.M. and 10:20 A.M., showed Resident #65 was in his/her recliner waiting on breakfast since 7:00 A.M. At 10:20 A.M., facility staff discussed that they did not have the Resident's breakfast. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a system to ensure hot foods that should be hot at breakfast and lunch, were served to residents at a temperature at or close to 120 degrees Fahrenheit (ºF). This practice potentially affected 72 residents who ate food prepared by the kitchen. The facility census was 73 residents. Record review of the facility's policy entitled Healthcare Culinary Group and Lifestyles, dated 1/1/21 showed: -All food items are evaluated for proper food temperature, taste and appearance prior to meal service. -Food and drinks should be palatable attractive and served at a safe and appetizing temperature, as determined by the type of food, to ensure patients'/residents' satisfaction. -All food (including pureed) will be tasted to evaluate flavor and consistency. -Any problems must be corrected prior to meal service. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to do the following: place a label on foods that were not easily identifiable; maintain the floors under the preparation table and the steam table free of debris, and food particles; maintain the ceiling vents over the food preparation area, free of dust; maintain the cucumbers free of mold; to prevent cross contamination by using the same spatula for turning the burgers and removing the burgers from the griddle; maintain three cutting boards free from numerous grooves and areas that were not easily cleanable; to check the temperature of sausage patties before they were pulled from the griddle. This practice potentially affected at least 70 residents who ate food from the kitchen. The facility census was 73 residents. 1. Observations of the lunch meal preparation on 1/10/22 from 9:25 A.M. through 1:20 P.M., showed: [...]

Inspectors wrote2. Record review of Resident #172's census log showed he/she admitted to the facility on [DATE]. Record review of the resident's vaccine tab in the electronic health record (EHR) showed no documentation regarding the resident's status of the influenza vaccine. Record review of the resident's hospital discharge instructions dated 1/4/22 showed no documentation regarding the influenza vaccine. Record review of the resident's EHR showed no documentation regarding the influenza vaccine being offered, declined or received. Based on interview and record review, the facility failed to offer or administer the influenza vaccine for four sampled residents (Residents #52, #172, #68 and #277) and to offer or administer the pneumonia vaccine for two sampled residents (Residents #68 and #277) out of 19 sampled residents. Five residents were sampled for immunizations. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent the existence of a negative balance for one discharged resident (Resident #173). The facility census was 73 residents. 1. Record review of the facility's Current Account Balance dated 1/13/22 showed Resident #173 had a negative balance of $18.00. During an interview on 1/20/22 at 11:55 A.M., the Regional Financial Analyst said: - The resident did not have a trust account at that time when he/she resided at the facility. - The previous Business Office Manager (BOM) used funds from the resident trust, to pay for hair care for Resident #173. - The facility should have contacted that resident's family or could have paid for that resident's hair care out of facility funds.

Inspectors wroteBased on interview and record review, the facility failed to submit a Third Party Liability (TPL) form (a form which is sent to Missouri (MO) Health Net, which gives an accounting of the remaining balance of that resident's funds in the resident trust account), which is required to be sent within 30 days after death, to MO Health Net after the death of one sampled resident (Resident #123), 125 days prior to the date of the resident fund review on [DATE]; and to submit the balance of the resident's funds to the estate of one sampled resident (Resident #127), who was a private pay resident. The facility census was 73 residents. 1. Record review of the clinical facility census dated [DATE] showed Resident #123 expired on [DATE]. Record review of the resident's resident trust statement, showed he/she had a balance of $1,288.36 in his/her account on date of his/her death. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from misappropriation of property when one bottle of Lorazepam (Ativan - an anti-anxiety medication) was missing and another bottle of Ativan had eight milliliters (ml) of medication that was unaccounted for during shift change narcotic count for one sampled resident (Resident #50), and there was also a discrepancy in the documentation of the amount of Lorazepam dispensed to the resident and the facility also had medication that appeared to have been replaced with a watery substance for two sampled residents (Resident #37 and #50) out of 17 sampled residents. The facility census was 72 residents. Record review of the facility's policy, Controlled Substance Policy, dated February 2021, showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide medications and treatments as prescribed by the physician for two sampled residents (Resident# 2 and #59) out of 19 sampled residents. The facility census was 73 residents. Record review of the facility's policy, Medication Administration, dated May 2019 showed: -The staff was to obtain and record any vital signs as necessary prior to medication administration. -The staff was to give the resident the medication. -The staff was to remain with the resident to ensure that the medication was swallowed. -The staff was to circle initials on the Medications Administration Record (MAR) if a medication was not given as ordered and record the reason in the as needed (PRN)/Omission Medication section of the MAR. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a discharge summary which included a recapitulation of the residents stay, and a reconciliation of the resident's post-discharge medication for one sampled closed record resident (Resident #72) out of three closed record residents. The facility census was 73 residents. Record review of the Discharge Summary and Plan policy reviewed 2/2021 states: -The Discharge Plan, Instructions, & Summary provides a recapitulation or summary of the resident's stay. -Discharge planning will begin upon admission to the Skilled Nursing Facility (SNF) and include family/caregiver plan for discharge. -Social Service Director or Social Service Designee will initiate and update the discharge plan in the Care Plan section of the resident's record. -Discharge Plan, Instructions, & Summary will include: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide assistance with toe nail clipping for one sampled resident (Resident #7) and did not provide assistance for activities of daily living for one sampled resident (Resident # 2) out of 19 sampled residents. The facility census was 73 residents. The facility did not have a policy related to nail care. Record review of the facility's undated job description, Certified Nursing Assistant (CNA) showed: -The staff was to assist residents with bath function as directed. -The staff was to assist residents with dressing as necessary. -The staff was to keep the residents dry change gown, clothing, linen when it becomes wet or soiled. -The staff was to assist in transporting the residents to/from appointments. -The staff was to perform after meal care, clean the resident's hands, face, clothing, brush teeth as needed. 1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure wound assessments were completed, to document treatments were completed, and to provide wound care for two sampled residents (Resident #59 and Resident #279) out of 19 sampled residents. They facility census was 73 residents. The facility policy was requested but was not provided. 1. Record review of Resident #59's face sheet showed he/she was admitted on [DATE] with the following diagnoses: -Sepsis (a life threatening complication of an infection) due to Methicillin Resistant Staphylococcus Aureus (MRSA - a group of bacteria that are difficult to treat as they are resistant to antibiotics). -Local infection of the skin and subcutaneous tissue (an infection that affects one part of the body). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident with a Foley catheter (a tube with retaining balloon passed through the urethra into the bladder to drain urine) had orders for the Foley catheter to include the reason for the catheter and for catheter care, and to provide catheter care for one sampled resident (Resident #36) out of 19 sampled residents. The facility census was 73 residents. Record review of the facility's Urinary Catheter Care policy dated 1/2017 showed: -The purpose of the procedure was to prevent catheter associated urinary tract infections. -Documentation should include the date and time catheter care was given. -The policy did not include what should be included on the order for a Foley catheter. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with a Percutaneous Endoscopic Gastrostomy tube (PEG tube - a tube that is placed into a patient's stomach as a means of feeding them when they were unable to eat) had orders for care, cleaning, and monitoring of the PEG tube site for one sampled resident (Resident #36), and failed to provide PEG tube care for two sampled residents (Resident #36 and #11) out of 19 sampled residents. The facility census was 73 residents. A policy for PEG tube care and PEG tube orders was requested and not received. 1. Record review of Resident #36's Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of having a gastrostomy tube (PEG). Record review of the resident's Care Plan dated 11/29/21 showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent (%). Two medication errors were observed out of 27 opportunities for an error rate of 7.4%. The facility census was 73 residents. Record review of the facility Medication Administration policy dated 5/2019 showed: -Staff should review the resident's Medication Administration Record (MAR). -Read and follow any special directions on the label. -Administer the medication and document the medication administration in the resident's MAR. Record review of the product insert for Humalog insulin (a fast acting insulin) dated 4/2020 showed the medication should be administered 15 minutes before or immediately after a meal. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure sausage was pureed (to make food into a paste or thick liquid suspension usually made from cooked food that was ground finely) to a smooth pudding or soft mashed potato consistency in accordance with the pureed sausage recipe. This practice potentially affected one sampled resident with a pureed diet. The facility census was 73 residents. 1. Record review of the undated pureed sausage recipe for 5 servings of pureed sausage showed: Ingredients: --5 sausage patties. --1/4 teaspoon of pork base. --½ cup hot water. --2 ½ pieces of toast. Directions showed: --Dissolve pork base in water to make broth. --Place prepared sausage patty, broth and toast in a washed and sanitized food processor. --Blend until smooth. [...]