Cassville Health Care Center

Inspectors wrote1. Please refer to event ID 1D693E-H3, exit date 02/02/26, for details.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety when the facility staff failed to keep food contact and non-food contact surfaces clean; when staff failed to ensure the refrigerators maintained proper temperatures for food storage; when staff failed to ensure stored food was properly stored/sealed; and when staff failed to ensure spoiled or contaminated foods were discarded. The facility census was 43. Review of the Food and Drug Administration (FDA) Food Code (2022 edition) showed the following: -Nonfood contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris;-Pathogens can be transferred to food from utensils that have been stored on surfaces which have not been cleaned and sanitized. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control system when flies were observed in multiple areas of the facility and multiple residents complained about the presence of flies in the facility. The facility census was 43. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not provide showers per resident preference for five residents (Resident #4, #5, #7, #9, and #10) who required staff assistance with showering. The facility census was 43. Review of the facility policy titled, Resident Showers Policy, dated 06/26/24, showed the following:-It is the practice of the facility to assist residents with bathing to maintain proper hygiene, stimulate circulation, and help prevent skin issues as per current standards of practice;-Residents will be provided showers as per request or as per facility schedule protocols based on resident safety.1. Review of Resident #4's face sheet showed:-readmission date of 04/22/24;-Diagnoses included atrial fibrillation (a cardiac dysrhythmia), stage 3 chronic kidney disease, and type 2 diabetes mellitus. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive care plan for each resident when staff did not address one resident's (Resident #7's) colostomy (a surgical procedure that creates an opening, called a stoma, on the abdomen to allow stool and gas to exit the body when the colon cannot), open wound, or activities of daily living (ADL) needs on his/her care plan. The facility census was 43. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to timely and adequately assess and treat one resident (Resident #1) with a toe and skin injury, when staff did not complete skin assessments weekly, did not timely obtain a mobile X-ray of the resident's foot as ordered by the physician, and when staff administered antibiotics to the resident, despite a listed allergy to the antibiotic. The facility census was 43. Review of the facility policy titled, Clean Wound Dressing Change Policy, dated 05/18/24, showed it is the policy of the facility to provide wound care in a manner to decrease potential for infection and/or cross contamination. Physician's orders will specify type of dressing and frequency of changes. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a licensed Administrator was available to the facility, that staff were aware of who the Administrator was, and that the Administrator was aware of and involved in the day-to-day happenings of the facility. This resulted in the facility not having sufficient staffing scheduled and available on-hand to ensure proper care resulting in multiple residents being left wet for extended periods of time; in staff not having access to administer ordered insulin and pain medications; allowing an unlicensed driver to transport residents; and failing to provide protective oversight of residents after a staff member was allowed to return with an investigation of allegations of misappropriation against a staff member ongoing. The facility census was 44. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent any future potential abuse, neglect, exploitation, or mistreatment while an investigation of misappropriation was in progress, when the facility allowed one staff member (RN A) to return to the facility to work as the only nurse on duty causing one resident (Resident #1) to be fearful of retaliation and taking steps to leave the facility due to the fear. The facility census was 44. The Administrator was notified on 09/08/25, at 2:18 P.M., of an Immediate Jeopardy (IJ) which began on 09/08/25. The IJ was removed on 09/08/25 as confirmed by surveyor on-site verification. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that pain management was provided to all residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences, when the facility failed to ensure staff had access to administer as needed pain medication as requested for one resident (Resident #4) who showed physical and verbal signs of pain. The facility census was 44. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain sufficient nursing staff to provide nursing and related services to assure resident safety and allow residents to maintain their highest practicable physical, mental, and psychosocial well-being, when the facility failed to maintain a nursing schedule to ensure sufficient staff were on-site to assist all residents resulting in nurses working over 24 shifts, lack of staff on-site to meet the needs all residents, and left the building unattended for a short period of time. This resulted in residents being left wet for an extended period of time and residents feeling concern regarding their well-being. The facility census was 44 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement policies that prevented abuse, neglect, and exploitation of residents when the facility did not complete the required preemployment screenings including Criminal Background Checks (CBC), Employee Disqualification List (EDL - a list of individuals not able to work in long-term care facilities in the state) checks, and Nurse Aide (NA) Registry (checks for a federal indicator of abuse that makes an individual unable to work in long-term care) checks and when the facility failed to ensure the staff had valid nursing licenses for two staff (Licensed Practical Nurse (LPN) F and LPN G) prior to the nurses working with the residents. The facility census was 44. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the current daily nurse staffing information in a clear and readable format and in a prominent place readily accessible to residents and visitors. The facility census was 44. Review of the facility's policy titled Nurse Staffing Posting Information Policy, revised 06/26/24, showed the following:-It is the policy of this facility to make nurse staffing information readily available in a readable format to residents and visitors at any given time;-The Nurse Staffing Sheet will be posted on a daily basis and will contain facility name; the current date; facility's current census; [...]

Inspectors wroteBased on interview and record review, facility staff failed to fully implement their infection control program when staff failed to ensure the required two step tuberculosis (TB-a communicable disease that affects the lungs characterized by fever, cough, and difficulty breathing) screening test was administered timely as per policy for two staff (Licensed Practical Nurse (LPN) F and LPN G) of two staff sampled. The facility census was 44. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide residents with a complete and fully functional call light system when the facility failed to provide staff with pagers for notification of call lights. This failure resulted in two residents (Resident #7 and #8) waiting for longer periods of time for staff to address incontinent care needs. The facility census was 42. Review of the facility policy titled, Call light Accessibility and Timely Response, revised [DATE], showed the following:-The purpose of this policy is to assure the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure a clean and homelike environment when multiple resident rooms had pest droppings present on the floor, in cabinets, on window ledges, and on tabletops. The facility had a census of 39. Review of facility records showed the facility did not provide a policy regarding housekeeping. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from misappropriation when a facility staff member coerced money from one resident (Resident #1) and when the staff member dispensed and did not administer or destroy narcotic medications of one resident (Resident #2). The facility census was 44. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents were free from unnecessary medications when staff administered medications to two residents (Resident #1 and #10) without following physician ordered monitoring. The facility census was 42. Review of the facility policy titled, Medication Administration, revised on 06/26/24, showed the following:-Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. It is the policy of this facility to ensure the safe and effective administration of all medication by utilizing best practice guidelines;-Obtain and record vital signs, when applicable or per physician orders. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all residents were free of significant medication error, when staff failed to administer insulin as ordered for three residents (Resident #5, # 6, and #7). The facility census was 44. Review of the facility policy, titled Medication Administration, revised 06/06/24, showed the following information:-Ensure the six rights of medication administration are followed included right resident, right drug, right dosage, right route, right time, and right documentation;-Administer medication as ordered;-Injections are administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice.1. Review of Resident # 5 face sheet (brief look at resident information) showed the following information:-re-admission date of 06/18/25;-Diagnoses included diabetes. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure prompt physician notification of resident laboratory results when staff failed to notify the physician timely of urinalysis/culture and sensitivity results (a urine sample grown in a lab to identify bacteria or other pathogen, and then tested against various bacteria to determine how effective different antibiotics are at killing the bacteria) for two residents (Resident #1 and Resident #5) with untreated urinary tract infections (UTIs). The facility census was 39. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure food was prepared and served in a manner that conserved the palability and nutritional value of the food when staff failed to follow the Registered Dietician (RD) approved recipes and menu resulting in residents being served smaller than approved of protein portion and the food being under seasoned. The facility had a census of 39. Review of a facility policy titled, Dietary Meal Service Policy, revised 07/05/23, showed meals were to be served in accordance with prescribed diets and state/federal regulation. 1. Review of a facility dietary document titled, Week at a Glance Week 1, dated 01/10/26, showed the lunch meal for 01/29/26 was beef goulash, buttered carrots, chef's choice dessert, and a beverage. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility, when the Transport Driver transported four residents (Resident #1, #9, #11 and #12) in the facility's van to physician appointments when his/her driver's license was suspended. The facility census was 44. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement an effective antibiotic stewardship program when staff failed to ensure the appropriate antibiotic was ordered for treatment of urinary tract infections (UTIs) for two residents (Resident #1 and Resident #5) resulting in the residents receiving antibiotics that their infections were resistant to. The facility census was 39. [...]

Inspectors wroteThis deficiency is uncorrected. For previous examples, refer to the Statement of Deficiencies dated 09/24/25. Based on observation, interview, and record review, the facility failed to provide an effective pest control system when the facility failed to take steps for pest control within the facility after multiple reported sightings of mice and mice droppings in multiple areas of the facility. The facility census was 42. Review of the facility policy titled, Pest Control Program Policy, revised 05/14/24, showed:-It is the purpose of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents;-Effective pest control program is defined as measures to eradicate and contain common household pests (e.g. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of misappropriation to the Department of Health and Senior Services (DHSS) and law enforcement within the required twenty-four hour timeframe when staff noticed and reported missing medications to the Administrator for three residents (Resident #1, #2 and #4) out of twelve sampled residents. The facility census was 44. [...]

Inspectors wroteThis deficiency is uncorrected. For previous examples refer to the Statement of Deficiencies, dated 09/24/25. Based on observation, interview, and record review, the facility failed to provide care per standards of practice when staff failed to monitor and accurately document regarding a bruise to the left lower extremity and failed to obtain ordered services in a timely manner for one resident (Resident #1). The facility census was 42. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have pharmacy systems in place to ensure proper administration of medications when staff entered two orders for the same medication for one resident (Resident #4) which resulted in errors in administration. The facility census was 42. Review of the facility policy titled, Medication Administration, revised on 6/26/24, showed:-Medications are administered by licensed nurses, other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide pharmacy services that ensured only appropriate licensed personnel administered medications when the facility allowed one certified nurse aide (CNA C) to administer medications to residents and perform blood sugar checks on residents. The facility's census was 45. Review of the facility's Administering Medications Policy, revised December 2012, showed the following information: -Medications shall be administered in a safe and timely manner, and as prescribed; -Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so; -The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions. 1. During an interview on 06/17/25, at 9:17 A.M., Resident #1 said the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each dependent resident received the necessary care and services to maintain good personal hygiene when staff failed to answer one resident's (Resident #1) call light in a timely leaving the resident wet for an extended period. Four residents were sampled and the facility had a census of 50. Review of the facility's policy titled Call Light Response Policy, undated, showed the following: -The purpose was to ensure that all residents' needs are met in a timely, respectful, and safe manner by providing an effective and reliable call light system and by establishing clear procedures for prompt staff response; -The facility is committed to maintaining a culture of safety and responsiveness. [...]

Inspectors wroteBased on record review and interview, the facility to provide care as per facility policy and the resident's care plan when staff failed to treat one resident's (Resident #3) rash in a timely manner. The facility's census was 45. Review of the facility's Change in a Resident's Condition or Status Policy, revised May 2017, showed the following: -The facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.); -The nurse will notify the resident's attending physician or physician on-call when there has been a need to alter the resident's medical treatment significantly; [...]

Inspectors wroteBased on interview and record review, the facility failed to protect all residents' right to be treated with dignity and respect when when two staff members (Certified Nursing Assistant (CNA) A and CNA B) entered the on resident's (Resident #1) room with out the resident's knowledge, rearranged items, and removed personal belongings. Six residents were sampled in the facility with a census of 54. Review of the facility's policy titled Quality of Life - Dignity, revised 08/2009, 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 meant the resident would be assisted in maintaining and enhancing his or her self-esteem and self-worth; -Residents' private space and property shall be respected at all times. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure establish an accurate system of administration of medications when staff failed to accurately document administration of topical medications and administer them within the parameters of physicians' orders for two residents (Resident #2 and Resident #3). Five residents were sampled out of a facility census of 54. Review of the facility's policy titled Medication Administration, undated, showed the following: -Document the administration after it is confirmed that the resident has taken the medication in the resident's medical record and sign; -Any discrepancies in medication administration must be immediately brought to the Director of Nursing (DON). The physician and family must be notified. An incident report needs to be completed. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed ensure food was protected from possible contamination per standards of practice when the facility failed to keep the ceiling in the kitchen and microwave free of debris and when the facility allowed dogs in the dining room during meals. The facility's census was 41. 1. Review of the facility's policy titled General Sanitation of Kitchen, undated, showed that food and nutrition services staff will maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule. Observations on 09/23/24, at 9:39 A.M., on 09/24/24, at 8:48 A.M., and 09/25/24, at 11:15 A.M., showed the following: -A three-foot by two-foot area of peeling paint on the ceiling above the food preparation table (the peeling paint could fall and contaminate food or food contact surfaces); [...]

Inspectors wroteBased on interview and record review, the facility failed provide a fully functioning Resident Council Group when the facility staff failed to address and provide feedback regarding concerns expressed residents attending resident council meetings. The facility census was 41. Review of the facility's policy titled, Resident Council, dated April 2017, showed the following: -The facility supports residents' rights to organize and participate in the Resident Council; -The purpose of the Resident Council is to provide a forum for residents, families and resident representative to have input in the operation of the facility. discussion of concerns and suggestions for improvement, consensus building and communication between residents and facility staff, and disseminating information and gathering feedback from interested residents; [...]

Inspectors wroteBased on observation, interview, and record review, failed to provide the maintenance services need maintain the fire doors to the facility resulting in residents have difficulty moving aobut the the faiclity #3, #18, #8, #5, #27 Review of the facility's policy titled, Quality of Life - Homelike Environment, dated May 2017, showed the following: -The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized and homelike setting. These characterizes include clean, sanitary and orderly environment; -Staff shall provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. 1. Observation throughout the the survey, 09/23/24 to 10/01/24, showed the following: -The smoke barrier doors closed and the magnetic hold-opend devices did not function appropriately; [...]

Inspectors wroteBased on record review and interview, the facility failed fully implement their abuse policy to prevent the hiring of staff that may be unable to work in the facility when staff failed to completed a Nurse Aide (NA) Registry (a registry that indicated a list of individuals who had a previous incident involving abuse, neglect, or misappropriation of property that would prevent the employee from working in a certified long-term care facility) check prior to starting employment and continued resident contact for three staff. The facility census was 41. Review of the facility's policy titled, Nursing Policy and Procedure subject of Abuse Prevention Program, dated 05/3/19, showed the following information: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all physician ordered medications were safe and fully effective when the staff had three expired medications in the facility's medications carts affect at least two residents (Resident #30 and #46). The facility census was 41. Review of the facility's policy titled, Storage of Medications, undated, showed the following: -The facility shall store all drugs and biologicals in a safe, secure, and orderly manner; -The nurse staff shall be reasonable for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner; -The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a functional, sanitary, and comfortable environment for residents, staff and the public, when staff failed to keep resident room floors a cleanable surface and failed to ensure the ceilings in good repair. The facility census was 41. Review of the facility's policy titled, Quality of Life - Homelike Environment, dated May 2017, showed the following: -The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characterizes include clean, sanitary, and orderly environment; -Staff shall provide person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed the protect each resident's right to have and use personal possessions when the facility failed move the personal possessions of two residents (Resident #3 and #27) when the staff moved the residents to different rooms. The facility census was 41. Review of the facility's policy titled, Quality of Life - Homelike Environment, dated May 2017, showed the following: -Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible; -Staff shall provide person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences; -The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide timely assistance to all dependent residents for bathing when staff failed to provide routine bathing for two residents (Resident #28 and #14) in a facility with a census of 41. Review of the facility's shower policy, revised 10/13/22, showed the following information: -The purposes of the procedure was to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident's skin. -The following information should be recorded on the resident's ADL record and/or in the resident's medical record: the date and time the shower was performed; the name and title of the individual(s) who assisted the resident with the shower; and if the resident refused the shower, the reason(s) why and the intervention taken. -Notify the supervisor if the resident refuses the shower. 1. [...]

Inspectors wroteBased on record review, observation, and interview, the facility failed to provide care per standards of practice when staff failed to to obtain a physician's order for treatment and administered a treatment without an order for reddened skin on one resident (Resident #1) and when the facility failed to obtain a urine sample for an ordered urinalysis for one resident (Resident #11) in a timely manner . The facility's censes was 41. 1. Review of the facility's policy/procedure titled, Medication Orders, revised November 2014, showed the following: -The purpose of this procedure was to establish uniform guidelines in the receiving and recording of medications orders; -Orders must be written and maintained in chronological order; -When recording treatment orders, specify the treatment, frequency and duration. [...]

Inspectors wroteBased on interview and record review, the facility failed to communicate and collaborate, consistent with professional standards of practice, with the dialysis (a process of filtering and removing waste products from the bloodstream when the kidneys can no longer sufficiently do so) center, failed to monitor fluid intake as care planned, and failed to implement interventions to manage dialysis treatment such as consistent weights to monitor fluid retention and dietary restrictions to manage elevated laboratory results for one resident (Resident #28), out of a sample of two residents. The facility census was 41. Review of the facility's Care of a Resident with End-Stage Renal Disease Policy, revised September 2010, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two residents received behavioral health services to maintain their highest practical psychosocial well-being when the facility failed to care plan and implement resident specific interventions and failed to follow-up on psychological services for one resident (Resident #24), and failed to follow-up with possible on psychological services after the resident exhibited an increase in his/her mood score and expressed desire to speak with a psychologist for one resident (Resident #28). The facility had a census of 41. 1. Review of Resident #24's face sheet (a brief summary of the resident's history) showed the following: -admission date of 10/14/23; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed ensure a medication error rate less that 5% percent when staff made two errors out of 25 opportunities (8% error rate) when staff failed to administered ordered medications to residents (Resident #11 and #2) during medication pass observation. The facility census was 41. Review of the facility policy/procedure titled, Medication Orders, revised November 2014, showed the following: -Medications should be reordered from the pharmacy in a timely manner to ensure no lapse of administration of medications; -For medications not received from pharmacy after reorder, nursing staff to follow up with pharmacy on availability and time frame to be delivered; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free of significant medication error when staff failed to administer insulin per physician orders, failed to document notification of the partial insulin doses, and failed to develop and implement specific interventions related to diabetes for one resident (Resident #24). The facility also failed to administer multiple doses of two medications ordered to manage one resident's (Resident #28) chronic kidney disease. The facility census was 41. Review of the facility policy/procedure titled, Medication Orders, revised November 2014, showed the following: -A current list of orders must be maintained in the clinical record of each resident. -Orders must be written and maintained in chronological order. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to maintain sufficient staff to provide an adequate showers/grooming, timely incontinent care and repositioning, and consistent and accurate wound tracking and treatments. The facility census was 50. 1. Record review of the Resident Census and Conditions form (form staff required to complete on annual survey) completed by the administrator, dated 11/30/22, showed the following information: -Census of 50 residents; -Forty-two residents required assistance of one totwo staff for bathing; -Five residents dependent on staff for bathing; -Thirty-seven residents required assistance of one to two staff for toileting; -Five residents dependent on staff for toileting assistance; -Forty-two residents required assistance of one to two staff for dressing; -Five residents dependent on staff for dressing assistance. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to have a registered nurse (RN) work eight consecutive hours seven days per week. The facility census was 50. Record review showed the facility did not provide a policy related to RN coverage. 1. Record review of the facility's time sheets for RN's for the month of 9/2022 showed the following: -On 9/5/22, the facility did not have eight consecutive hours of RN coverage; -On 9/11/22, the facility did not have eight consecutive hours of RN coverage; -On 9/12/22, the facility did not have eight consecutive hours of RN coverage; -On 9/26/22, the facility did not have eight consecutive hours of RN coverage. Record review of the facility's nurse schedule for the month of 11/2022 showed the following: -On 11/14/22, the facility did not have eight consecutive hours of RN coverage; [...]

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. Record review of the facility's policy titled Food Services Manager, revised 12/2008, showed the following: -The daily functions of the Food Services Department are under the supervision of a qualified Food Services Manager; -The Food Services Manager is a qualified supervisor licensed by this state and is knowledgeable and trained in food procurement storage, handling, preparation, and delivery; -The Food Services Manager is responsible for the daily functions of the Food Services Department in accordance with the facility's department policies and procedures. Additional responsibilities of the Food Services Manager include: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to store and prepare food in accordance with professional standards of practice and protect all food from possible contamination when the facility staff failed to ensure foods were held at an appropriate temperature to inhibit the growth of pathogens that can cause foodborne illness; staff failed to label and date open and left over food containers; staff improperly thawed potentially hazardous food; staff failed to discard dented cans when staff stored dented cans on the shelves along with cans of food staff used to prepare resident food; staff failed to discard expired food stored on the shelves along with food used to prepare resident food; staff failed to store food in a container that could not seal to prevent contamination; [...]

Inspectors wroteBased on interview and record review, 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 had a census of 50. Record review of the CDC (Centers for Disease Control and Prevention) Toolkit for Legionella (also titled Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings), dated 03/25/2021, showed healthcare facilities need to actively identify and manage hazardous conditions that support growth and spread of Legionella by: [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an infection prevention control program (IPCP) that included a functional antibiotic stewardship program with a effective system to monitor resident antibiotic use and potential trends of infections in the facility. The facility census was 50. Record review of the facility policy titled Surveillance for Infections, revised July 2016, showed: -The infection preventionist will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative intervention; [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an infection prevention control program (IPCP) that included a qualified infection preventionist on at least a part-time basis. The facility census was 50. Record review of the facility policy titled, Surveillance for Infections, revised July 2016, showed: -The infection preventionist will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative intervention; -The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and HAIs, to guide appropriate interventions, and to prevent future infections; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to eliminate flies from the facility when multiple flies were present and buzzed around and landed on one resident (Resident #35) and when multiple flies were present in the kitchen and landed on various food prep items for resident use in the facility kitchen. The facility census was 50. 1. Record review of Resident #35's face sheet showed: -admission date of 6/7/22; -Diagnoses included anxiety disorder, depression, and dementia with psychotic disturbance. Observation on 11/27/22, at 11:35 A.M., showed the resident lying on a mattress on his/her floor. The resident wore a nightgown and an odor of urine permeated the resident's room. Five flies buzzed the resident landing on the resident's arms and top sheet. The resident said, I want to get up, come on, come on. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain sufficient staff to provide bath/showers as preferred for four residents (Resident #6, Resident #8, Resident #28, and Resident #148) The facility census was 50 . Record review of the facility policy titled, Activities of Daily Living, undated, showed the following: -Policy to provide resident care (i.e. dressing, grooming, hygiene, bathing, toileting) in accordance with the assessed needs and abilities of the resident with a goal of promoting and maintaining those abilities; -Purpose to meet the care and needs of the residents through identification and consideration of their varying abilities as their specific aging and disease progressing; -Staff should recognize that each resident requires individualized, creative care. 1. Record review of Resident #2's face sheet showed: -admitted to the facility on [DATE]; [...]

Inspectors wroteBased on interview and record review, the facility staff failed to ensure an admission Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff) was completed for three resident (Resident #101, Resident #150 and Resident #248). The facility census was 50. 1. Record review of Resident #101's face sheet (admission data) showed an admission date of 10/3/22. Record review of the resident's MDS assessments showed the following: -Staff completed an entry assessment on 10/3/22; -Staff completed a five day assessment on 10/10/22; -Staff completed a discharge assessment on 10/12/22. Record review of the resident's progress note dated 10/12/22, at 10:41 A.M., showed a nurse documented the resident discharged to home with medications. The resident exited the facility at 9:30 A.M. accompanied by a family member by private vehicle. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff) assessments were completed within the required timeframe for six residents (Resident #2, Resident #6, Resident #19, Resident #22, Resident #33 and Resident #35). The facility census was 50. 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 MDS completion date (item Z0500B) must be no later than 14 days after the Assessment Reference Date (ARD-the specific end-point for the look-back period in the MDS assessment process). 1. Record review of Resident #2's MDS assessment showed staff completed a quarterly assessment on 7/21/22. [...]

Inspectors wroteBased on interview and record review, the facility failed to electronically transmit encoded Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff) assessments from the facility to the Centers for Medicare & Medicaid Services (CMS) Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system within 14 days after completion for ten residents (Resident #4, Resident #5, Resident #9, Resident #12, Resident #13, Resident #17, Resident #20, Resident #21, Resident #23 and Resident #30). The facility had a census of 50 residents. Record review showed the facility did not have a policy regarding transmitting MDS data. 1. [...]

Inspectors wroteBased on record review and interview, the facility failed to develop a comprehensive person-centered care plan for five residents (Resident #6, Resident #19, Resident #33, Resident #101 and Resident #150 ) that included measurable objectives to meet the resident's medical and nursing needs as identified in the comprehensive assessment. The facility census was 50. Record review of the facility's policy titled Care Plans, Comprehensive Person-Centered, revised 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; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate activities of daily living (ADLs - dressing, grooming, bathing, eating, and toileting) assistance to seven dependent residents when staff failed to provide timely incontinent care to one resident (Resident #19), failed to provide timely incontinent care and adequate assistance with dressing and grooming to one resident (Resident #22), failed to provide timely incontinent care and adequate oral care to one resident (Resident #35), and failed to provide an adequate number of showers to three residents (Resident #6, #14, and #37). The facility census was 50. Record review of the facility policy titled, Activities of Daily Living, undated, showed: -Policy to provide resident care (i.e. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely and routine assessments, treatment, care plan updates, and notification of the physician for one resident (Resident #99) with a change in condition of a sacrum/coccyx (large bone at base of the spine/tailbone) pressure ulcer (a local 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); failed to provide timely repositioning, assessment, treatment, care planning, and notification of the physician for one resident (Resident #19) with a pressure ulcer to his/her left hip; and failed to provide timely assessment, monitoring, physician notification, and treatment for one resident (Resident # 14) with open areas to his/her posterior thigh. The facility census was 50. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain signed informed consent and physician orders for side rails, failed to add side rails to the resident's care plans for three residents (Resident #29, Resident #37 and Resident #248), and failed to complete side rail assessments on a regular basis on two residents (Resident #29 and Resident #37). The facility census was 50. Record review of the facility's policy titled Bed Safety, revised 12/2007, showed the following: -The facility shall strive to provide a safe sleeping environment for the resident; -The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all residents received proper nutrition at all meals when staff did not follow recipes/menus when preparing and serving food resulting in residents receiving portions smaller than called for by menu/recipe The facility's census was 50. Record review of the facility's policy titled Kitchen Weights and Measures, revised 04/2007, showed the following: -Food Services staff will be trained in proper use of cooking and serving measurements to maintain portion control; -Staff will be trained in the comparison of volume and weight measures; -Recipes will specify consistent use of metric or U.S. measurement guidelines; -Serving utensils used will be consistent with choice of metric or U.S. measure used; -Staff will be trained in the appropriate measurement and type of serving utensil to use for each food. [...]

Inspectors wroteBased on record review, observation, and interview, the facility failed to provide privacy for two residents (Resident #36 and Resident #248) by failing to replace a privacy curtain in their room. The facility census was 50. Record review of the facility's policy titled Quality of Life - Dignity, revised 8/2009, showed the following: -Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality; -Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth; -Staff shall promote, maintain, and protect the resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. 1. Record review of Resident #36's face sheet (a document that gives a patient's information at a quick glance) showed the following: [...]

Inspectors wroteBased on interview, and record review, the facility failed to update the Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff) with a Significant Change in Status Assessment (SCSA) within 14 days after a significant change in status had occurred for one resident (Resident #99). The facility census was 50. 1. Record review of Resident #99's face sheet (admission data) showed the following: -Resident admitted on [DATE]; -Diagnoses included chronic kidney disease stage 3 (kidneys have mild to moderate damage and are less able to filter waste and fluid out of blood), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures). [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to routinely and accurately monitor and assess a wound for one resident (Resident #28) and failed to identify, notify the physician of, obtain treatment orders in a timely fashion, and monitor one resident's (Resident #99) wound. The facility census was 50. Record review showed the facility did not provide a policy for notification to the physician of a change in condition. Record review of the facility's form Situation, Background, Assessment, Recommendation (SBAR) Communication Form, dated 2014, showed the following: -Before calling the physician, nurse practitioner, physician assistant/other healthcare professional: evaluate the resident, check vital signs, review record, review an 'Interact' care path or acute change in condition file card if indicated, and have relevant information available when reporting; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #150) who received dialysis (a treatment to clean blood when the kidneys are not able to. It helps the body remove waste and extra fluids in the blood) was properly monitored for potential complications related to dialysis, when staff did not did not have specific orders for frequency of monitoring of the resident's dialysis central venous catheter (an intravenous line into a vein in the resident's chest), did not document any monitoring, and did not have a person-centered care plan related to dialysis care needs. The facility census was 50. Record review of the facility policy titled Dialysis-General Guidelines and Management, dated 5/2017, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure two staff (Registered Nurse (RN) N and Certified Nursing Assistant (CNA) F were granted a qualifying exemption prior to starting their employment. The facility failed to fully implement their Staff Vaccination Policy for COVID-19 by failing to implement additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19. Unvaccinated staff failed to properly wear N95 (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) face masks and perform Coronavirus Disease 2019 (COVID-19) testing for unvaccinated staff per facility policy. The facility census was 50. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to keep food safe from potential contamination when the appliances and the exterior louvers on the range hood had a build-up of grease and lint. Staff stacked clean dishware inside one another prior to being air dried which all could potentially contaminate food prepared for residents. The facility census was 46. Record review of the facility's policy, titled Sanitation, Med-Pass, Inc., revised 2008, showed the following information: -The food service area shall be maintained in a clean and sanitary manner; -All equipment, food contact surfaces, and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions; -Food preparation equipment and utensils that are manually washed will be allowed to air dry; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control system for control of roaches and flies. The facility census was 46. Record review of the facility's policy, titled Pest Control, Med-Pass, Inc, revised May 2008, showed the following information: -The facility maintains an on-going pest control program to ensure the building is kept free of insects and rodents; -Pest control services will be provided by (left blank to insert a company here); -Garbage and trash are not permitted to accumulate and are removed from the facility daily, and; -Maintenance services assist, when appropriate and necessary, in providing pest control services. [...]

Inspectors wroteBased on interview and record review, the facility failed to check the Nurse Aide (NA) Registry for four staff (Dietary Aide (DA) I, Activity Director, Business Office Manager, and Certified Nurse Aide (CNA) G) out of eight sampled staff to ensure they did not have a Federal Indicator (a marker given to a potential employee who has committed abuse, neglect, or misappropriation of property against residents) prohibiting them to work in a certified facility. The facility failed to conduct criminal background checks on two staff (CNA B and Activity Director) out of eight sampled staff to ensure the residents are protected from harm; [...]

Inspectors wroteBased on interview and record review, the facility failed to immediately begin an investigation of an allegation of abuse, per facility policy; and failed to ensure resident safety after an allegation of abuse when the facility continued to allow the alleged perpetrator (Certified Nurse's Aide (CNA) B) to assist residents after an allegation of abuse, in a sample of 14 residents. The facility census was 46. Record review of the facility's Abuse and Neglect Policy and Procedures, revised on 3/3/17, showed the following: -Purpose: to establish guidelines that identifies and report resident abuse -Policy: The resident has the right to be free from verbal, sexual, physical and mental abuse. -To ensure each resident is treated with dignity and care, free from abuse and neglect and to take swift and immediate action to investigate and adjudicate alleged resident abuse. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain informed consent for side rails and failed to complete a bed rail safety check to include measurements of the bed frame and bed rails for risk of entrapment for four residents (Resident #2, #13, #34 and #45) out of a sample of 14 residents. The facility census was 46. Record review of the facility's policy entitled, Bed Safety (Revised December 2007), showed the following information: -The facility shall strive to provide a safe sleeping environment for the resident; -The resident's sleeping environment shall be assessed by the interdisciplinary team, with input from the resident and family; -To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain proper infection control practices based on facility policy and acceptable standards of practice for 2019 Novel Coronavirus Disease (COVID-19) pandemic, when staff did not properly wear face coverings in resident common areas of the facility, and staff did not follow the facility's screening process policy upon entrance to the facility. The facility failed to ensure staff followed policies and acceptable standards of practice when staff did not appropriately administer, read, and document results for the two-step tuberculosis (TB; infectious lung disease) tests for three residents (Residents #39, #45, and #248) out of 12 sampled residents. Staff failed to pre-clean the rubber stoppers prior to insulin pen needle insertion for two residents (Resident #40 and #41). The facility census was 46. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, homelike environment for the residents, including one resident (Resident #23). A sample of 14 residents was selected for review; the facility census was 46. 1. Record review of Resident #23's annual Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument, completed by facility staff, dated 7/9/2020, showed the following information: -admitted to the facility on [DATE]; -Cognition intact; -Independent for all activities of daily living; -Diagnoses included chronic obstructive pulmonary disease (COPD; breathing disorder), sleep apnea (breathing disorder), anxiety, depression, insomnia, and high blood pressure. Record review of the resident's care plan, last revised 6/12/2020, showed the following information: [...]

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe when one resident (Resident #3) out of a selected sample of 14 residents reported sexual abuse during care. The facility's census was 46. Record review of the facility's Abuse and Neglect Policy and Procedures, last revised on 3/3/17, showed the following: -Purpose: to establish guidelines that identifies and report resident abuse -Policy: The resident has the right to be free from verbal, sexual, physical and mental abuse. -Residents must not be subjected to abuse by anyone, including facility staff. -Abuse is defined as the willful infliction of injury to attain or maintain physical, mental and psychosocial well-being. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to timely assess, notify the physician of, and provide treatment for one resident (Resident #21) who had pressure ulcers on his/her heels, out of a selected sample of 14 residents. The facility census was 46. Record review of the U.S. Department of Health and Human Services Clinical Practice Guidelines, Number 15, Treatment of Pressure Ulcers, showed the following information: -Assess the pressure ulcer initially for location, stage, size, tracts, exudate (any fluid that has been forced out of the tissues or its capillaries because of the inflammation or injury), necrotic tissue (death of tissue in response to disease or injury), and presence or absence of granulation tissue (formation of new tissue, usually pink to red in color) and epithelialization (healing by the growth of epithelium over a denuded surface); [...]