Clara Manor Nursing Home

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #1) was free from physical abuse when Certified Medication Technician (CMT) A put the palm of his/her hand over the resident's mouth and squeezed really hard, resulting in a scratch on the resident's right cheek, a circular bruise on the resident's left cheek, and the resident stating he/she was scared to death. The resident told two staff members and the facility failed to protect the resident by allowing CMT A to continue working his/her shift until 9:00 P.M. Twelve residents were selected for review. The facility census was 89 residents. The Administrator was notified on 11/18/25 at 1:20 P.M. of Immediate Jeopardy (IJ) which began on 11/12/25. The IJ was removed on 11/19/25. [...]

Inspectors wroteBased on interview and record review, the facility failed to report to local law enforcement an allegation of abuse of Resident #1 by Certified Medication Technician (CMT) A. Twelve residents were selected for review. The facility census was 89 residents. Review of the facility's undated policy titled, Abuse and Neglect showed the definition of abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure they employed a Registered Nurse (RN) for eight consecutive hours per day, seven days per week. The facility census was 88. The facility did not provide the requested nurse staffing policy. Review of the staffing sheets for May 2025 showed no RN scheduled for eight consecutive hours on 05/02, 05/10, 05/11, 05/22 and 05/23. During an interview on 10/17/2025 at 02:40 P.M., the Administrator said they should have RN coverage eight hours a day, seven days a week.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to store, prepare and serve food in accordance to professional standards of food service safety when staff failed to date, label, and store food items correctly, failed to maintain environmental and cleanliness standards for the kitchen, failed to adhere to proper standards for personal hygiene and handwashing, and failed to perform daily temperature checks on kitchen equipment. The facility census was 88. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure four of the 18 sampled Residents (Resident #2, #6, #8, and #12) reviewed for unnecessary medications, and/or their representative were informed of the risks and benefits of a physician ordered antipsychotic, antidepressant, or anti-anxiety medication. The facility census was 88. Review of the facility's Resident Rights Dignity and Privacy policy, undated, showed:- Residents have a right to know about their medical condition and treatments;- Make decisions about their medical care and activities;- Have the right to be informed of all aspects of your care, to participate in planning your care and treatment, including any changes in care and treatment;- Have the right to refuse treatment and to be informed of the consequences of such refusal.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a homelike environment in the dining room when basic utensils and condiments were not made available, sandwiches were served in plastic bags and residents were not asked what they wanted to eat before being served. Additionally, the facility failed to ensure a homelike environment in the resident hallways by not properly overseeing facility pets which caused unpleasant odors for two Residents (Residents #31 and #43). The facility census was 88. Review of the facility's Resident Rights-Dignity and Privacy Policy, undated., showed all Residents have the right to not have their life regulated beyond what is necessary in providing resident services;Request for policy covering Homelike Environment could not be provided;1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there were no expired stock medications in the medication carts, failed to ensure all stock medications were dated when opened, failed to label an inhaler with the resident's name for one of the 18 sampled residents (Resident #1), and failed to date opened pens of Insulin for two of the 18 sampled residents, (Resident #73 and #79). The facility census was 88. Review of the facility's Using Stock Medications policy, dated 2024, showed:- Check or place the appropriate labels on the container. Initial name, title, and date. Review of the facility's Insulin Administration policy, dated 2024, showed:- The nurse shall label the insulin with a date and initials upon opening;- The nurse shall dispose of the insulin after 28 days (or as recommended by the manufacturer) from the date labeled on the bottle. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff provided care in a manner to prevent infection or the possibility of infection when staff did not use proper Enhanced Barrier Precaution (EBP) signage for two residents with indwelling medical devices Resident #42 and #85 and when Certified Medical Technician (CMT) A failed to wash his/her hands and apply clean gloves before he/she administered medications for two residents Resident #79 and Resident #70. This affected four of the 18 sampled residents (Resident #42, #85, #79 and #70). The facility census was 88. Review of the facility's Enhanced Barrier Precautions policy, undated, showed:- Enhanced Barrier Precautions (EBP) are intended to be used for the duration of a resident's stay in a facility. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to protect the resident's rights, when the facility did not post the State Survey Agency contact information for Residents (Residents #13, #38, and #86) and anyone else who wanted to file a complaint. The facility census was 88. Review of facility's Resident Rights-Dignity and Privacy policy, undated, showed:- All residents have the right to complain and be heard;- Residents have the right to free access to any representative of the state or federal government. 1. Review of Resident #38's Quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 9/30/25, showed:- The resident is cognitively intact;- Diagnosis: diabetes, cerebral palsy, anxiety disorder, bipolar disorder, and depression. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to protect the rights of residents, when the facility did not provide access to read or view the most recent State Survey Inspection conducted at the facility. This affected all residents. The facility census was 88. Review of the facility's undated Resident Rights-Dignity and Privacy Policy showed all Residents have the right to examine results of facility inspections including plans of correction.1. Review of Resident #86's Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, was not available. During an interview on 10/17/25 at 9:15 A.M., the Resident said he/she had not seen the state survey book and had not known where it was supposed to be kept for review. 2. Review of Resident #13's Annual MDS, dated [DATE], showed:- The Resident was cognitively intact:- Diagnosis: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one Resident (Resident #77) remained free from smoke and fire hazards when the facility failed to prevent a resident from smoking in an unauthorized location in the facility. The facility census was 88. Review of facility's undated, Smoking Policy, showed;- Residents are to only smoke in posted designated areas during designated times posted on the first and second floors. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect one out of six sampled residents (Resident # 1) from physical abuse. On 6/22/25, around 1:30 A.M., Certified Nurse Aide A became aware of Resident #1 and #2 getting into an altercation at the 2nd floor nursing station. Resident #1 wanted to get some ice and Resident #2 blocked the area with his/her wheelchair and would not let him enter. Resident #1 stated he cursed and threw a small amount of the remaining water in his water pitcher on Resident #2. Resident #2 yelled at Resident #1 and stated Resident #1 had called him/her racial names and threw water at him/her. Resident #1 went back to his own room. After Resident #1 left, Resident #2 told CNA A he/she was going to call his/her cousin and put a wood under his/her ass. The nurse aide advised Resident #2 to calm down and return to his/her room for the night. [...]

Inspectors wroteRefer to F600 Event ID 66SW12 Based on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #69) was free from physical abuse, when on 1/10/25 at approximately 10:00 P.M., Resident #76 willfully hit Resident #69 on his/her face, resulting in swelling and pain. Resident #72 stated Resident #76 had threatened to beat up people and was violent. The facility census was 86 residents. An Abuse/Neglect policy was requested from the facility, but was not provided. Review of the facility's Abuse and Neglect Educational Material; Policy Regarding Abuse and Neglect of Facility Residents, undated showed: -Resident rights protected them from physical and mental abuse. -Abuse was defined as a willful infliction of injury. -Physical force that may result in physical pain or impairment included: [...]

Inspectors wroteRefer to F622 Event ID 66SW12 Based on interview and record review, the facility failed to plan, coordinate, and provide a safe and appropriate discharge when the facility initiated an immediate discharge for one sampled resident (Resident #76) out of 36 sampled residents. The resident's discharge notice stated the transfer location was Facility B, however, the resident was transported to the hospital via Emergency Medical Services. Facility B was unaware the resident was to be discharged to them. The facility census was 86 residents. Review of the facility's Discharge and Transfer Resident policy, dated 12/21/24, showed: -The purpose of the policy was to ensure the appropriate procedure for transferring and discharging a resident. -All residents who were discharged out of the facility under any circumstance was given an order from the attending physician. [...]

Inspectors wroteRefer to F623 Event ID 66SW Based on interview and record review, the facility failed to provide an appropriate discharge notice for one sampled resident (Resident #76) out of 36 sampled residents, when the Discharge Notice issued to the resident had incorrect contact information for the Ombudsman, incorrect contact information in order for the resident to appeal the discharge, and did not have the correct discharge location listed on the notice. The facility census was 86 residents. Review of the facility's Discharge and Transfer Resident policy, dated 12/21/24, showed: -The purpose of the policy was to ensure the appropriate procedure for transferring and discharging a resident. -Involuntary discharges must: --Be reviewed by the Safety Committee. --The physician shall be consulted. --Can be immediate in the case of emergency due to: [...]

Inspectors wroteRefer to F740 Event ID 66SW12 Based on observation, interview and record review, the facility failed to effectively manage behaviors by not providing appropriate behavior interventions for one sampled resident (Resident #76) when the resident physically assaulted and injured Resident #69 by hitting him/her in the face causing pain, swelling, and redness. The facility census was 86 residents. Review of the facility's Behavior Management Program, undated, showed: -A behavior symptom was defined as an indication or characteristic of a negative physical or psychosocial outcome which may have resulted in disturbing of others. -A behavior could also inhibit the resident in attaining or maintaining his/her highest practical well-being. -The purpose of the policy was to promote a healthy environment that provided comfort to all residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #69) was free from physical abuse, when on 1/10/25 at approximately 10:00 P.M., Resident #76 willfully hit Resident #69 on his/her face, resulting in swelling and pain. Resident #72 stated Resident #76 had threatened to beat up people and was violent. The facility census was 86 residents. An Abuse/Neglect policy was requested from the facility, but was not provided. Review of the facility's Abuse and Neglect Educational Material; Policy Regarding Abuse and Neglect of Facility Residents, undated showed: -Resident rights protected them from physical and mental abuse. -Abuse was defined as a willful infliction of injury. -Physical force that may result in physical pain or impairment included: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to effectively manage behaviors by not providing appropriate behavior interventions for one sampled resident (Resident #76) when the resident physically assaulted and injured Resident #69 by hitting him/her in the face causing pain, swelling, and redness. The facility census was 86 residents. Review of the facility's Behavior Management Program, undated, showed: -A behavior symptom was defined as an indication or characteristic of a negative physical or psychosocial outcome which may have resulted in disturbing of others. -A behavior could also inhibit the resident in attaining or maintaining his/her highest practical well-being. -The purpose of the policy was to promote a healthy environment that provided comfort to all residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Dietary Manager (DM) met one of the qualifications for a Certified Dietary Manager (CDM) by having a national certification for food service management and safety, from a national certifying body, or at least an associate's degree in food service management or in hospitality, or had 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management. This practice potentially affected all residents. The facility census was 89 residents. 1. Review of the new Employee hire list showed the DM was hired on 9/7/23. During an interview on 11/18/24 at 12:49 P.M., the DM said he/she has worked as as DM since September 2023 and the facility has not assisted him/her in obtaining the requirements to be a CDM. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to follow the menu on the following three occasions: Lunch on 11/17/24, lunch on 11/19/24 and dinner on 11/19/24. This practice potentially affected all residents. The facility census was 89 residents. 1. Review of the Week at Glance menu dated 2024 showed the 11/17/24 lunch meal consisted of: -Fried chicken. -Mashed potatoes with gravy. -Mixed greens. -Homemade Peach Crisp. -Dinner roll. Observation during the lunch service 11/17/24 from 11:45 A.M. through 12:35 P.M., showed the Homemade Peach Crisp was not served. During an interview on 11/178/24 at 11:53 A.M., Dietary [NAME] (DC) A said he/she ran out of time to make the Homemade Peach Crisp. 2. Review of the Week at Glance menu dated 2024 showed the 11/19/24 lunch meal consisted of: -Sweet and Sour Chicken. -Steamed Rice. -Oriental Vegetables. [...]

Inspectors wroteBased on interview and record review, the facility failed to have an certified Infection Preventionist (IP) employed at the facility. The facility census was 89 residents. Review of the facility's undated policy, Required Primary Professional Training for Infection Preventionists, showed: -This policy was to define the primary professional training requirements for Infection Preventionists to ensure they possessed the knowledge and skills necessary to manage and prevent infections in healthcare environments. -The Infection Preventionist must complete training programs offered through CDC TRAIN (a comprehensive platform that provides access to online training materials and resources from the Centers for Disease Control and Prevention). -All completed training and certifications through CDC TRAIN must be documented and maintained in the employee's personnel record. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to carry out pest control measures to limit the presence of roaches in the kitchen, the dining room, and in resident rooms 214 and Resident #25's room. This practice affected all areas of the kitchen and the part of the dining room next to the kitchen. The facility census was 89 residents. 1. Observations on 11/17/24 from 8:58 A.M. through 12:47 P.M., showed: -Dead roaches in the drawer under the table with the microwave. -Roaches crawling on the wall behind reach-in refrigerator -Roaches inside of the electrical outlet behind ice machine. -Numerous roaches under the dishwasher, where there was a buildup of grime and food debris. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the required annual 12 hours of in-service training for Certified Nursing Assistants (CNA), and maintain records which indicate the subject of, and attendance at, all in-service sessions. The facility census was 89 residents. Review of the facility's CNA Continuing Education policy dated 5/25/23 showed: -All CNA's must complete a minimum of 12 hours of continuing education annually, in accordance with state and federal regulations. -Education may be provided through: --On-site training sessions. --Online learning platforms approved by the facility. --Workshops and seminars. -Supervisors will track compliance and maintain records in personnel files. -Failure to meet continuing education requirements may result in: --Written warnings. --Suspension of shifts until compliance is achieved. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the required bond amount was sufficient for the amount of the average monthly balance for the 12-month period from 11/23 through 10/24. This practice potentially affected 56 residents who allowed the facility to manage their resident trust accounts. The facility census was 89 residents. 1. Review of the Resident Funds Bond Worksheet showed: -The average monthly balance for 12 months of reconciled bank statements was $123,720.44. -The directions on the Resident Fund Bond Worksheet stated that amount should be rounded to the nearest thousand up or down. When rounded up, that amount was $124,000.00 -The directions on the Resident Funds Bond Works sheet then stated to multiply that amount by 1.5, after multiplied, that amount was $186,000.00. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the handrails in the dining room free from a buildup of food crumbs; failed to maintain the restroom ceiling vents free of a dust buildup in the following resident rooms: 202, 203, 204, 205, 206, 209, 211, 223, 104, 103, 107, 108, 109, 111, and 112; failed to maintain the large orange fan at the north end of the first floor free from a buildup of dust; failed to maintain resident use fan in the following rooms free from a buildup of dust: resident rooms 201, 209, 104, and 111. This practice potentially affected at least 55 residents who resided in those rooms or used those areas. The facility census was 89 residents. 1. Observation on 11/17/24 at 9:24 A.M., showed: -A buildup of food crumbs in the handrails which were on the north wall of the dining room. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were not left at bedside for two sampled residents (Residents #23 and #50) and one supplemental resident (Residents #27) out of 18 sampled residents. The facility census was 89 residents. The facility did not have a policy regarding leaving medications at bedside or self medicating. 1. Review of Resident #23's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Depression (a common mental health condition that involves a long-lasting low mood or loss of interest in activities). -Psychosis (a mental disorder characterized by a disconnection from reality). -Vascular Dementia (brain damage caused by multiple strokes (damage to the brain from an interruption of its blood supply). [...]

Inspectors wroteBased on interview and record review, the facility failed to have a process in place to ensure Cardiopulmonary Resuscitation (CPR-a lifesaving technique useful in many emergencies, in which someone's breathing or heartbeat has stopped) certifications were on file for all staff with current CPR certification and certified staff were available on all shifts. This had the potential to affect 80 residents who were a full code status (would require CPR). The facility census was 89 residents. Review of the facility policy titled Policy for Medical Emergency Response dated 2023 showed: -At least one staff member must obtain CPR certification each shift, which may be a non-nursing staff member. -The facility will maintain a record of any staff members who are trained and capable of providing CPR and will be able to demonstrate current competency. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain acceptable nutritional status by not following physician instructions for weighing residents resulting in an unplanned weight loss for one sampled resident (Resident #56) out of 18 sampled residents. The facility census was 89 residents. Review of the facility's policy titled, Weight Management - Unplanned Weight Change dated 2023 showed: -The Director of Nursing (DON)/Assistant DON (ADON) would be responsible for establishing monthly/weekly weight schedule. -The appointed nursing staff were responsible for obtaining weight for each resident according to the schedule. -The staff who were responsible for weighing the residents would compare the current weight and the previous weight and re-weigh the resident if there was a five or more pound change. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory equipment such as oxygen tubing, Continuous Positive Airway Pressure (CPAP - a method of noninvasive ventilation assisted by a flow of air delivered at a constant pressure throughout the respiratory cycle), and a nebulizer (a device that was used to administer medication in the form of a mist inhaled into the lungs) were cleaned and stored in a sanitary condition for three sampled residents, (Resident #22, #34, and #62) out of 18 sampled residents. The facility census was 89 residents. Review of the facility's policy, Respiratory Therapy Policy, dated 2022 showed: -The equipment should have the individual's name and have been cleaned by the staff (the policy did not stated how often) and as needed. -Tubing, cannula, and bottle should have been stored properly in an infection controlled manner. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staffing was posted correctly at the beginning of each shift including the total number and actual hours of nursing staff worked per shift which could have the potential to affect all visitors and residents in the facility. The facility census was 89 residents. A policy regarding posting staffing was requested but not received at the time of exit. Observation on 11/17/24 at 8:30 A.M., showed: -No posted staffing noted at the front entrance reception or the first-floor nurse's station. During an interview on 11/17/24 at 9:40 A.M., Certified Medication Technician (CMT) C said: -He/She was not sure where the staffing sheets were located, he/she said probably at the nurse's station. -The first floor had one Registered Nurse (RN), one CMT, and one Certified Nursing Assistant (CNA) for this shift. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the only sink in the Medication Room on the first floor was clean, failed to ensure staff was checking the refrigerator temperature which held the residents prescribed medications, failed to ensure there were no expired medications in the medication refrigerator, and failed to ensure resident's prescribed medications were stored in a dry environment. The facility census was 89 residents. Review of the facility's policy,Storing Medications/Medication Carts, dated 2019 showed: -Drugs were to have been stored at proper temperatures. -Drugs requiring storage at room temperatures were to have been stored at a temperature of not less than 36 degree Fahrenheit (F) or more than 46 degrees F. -A thermometer was to have been kept in the refrigerator containing medications to help assure proper temperatures. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure that Dietary Aide (DA) A's hair completely within a hair restraint; failed to ensure a bottle of jelly was refrigerated according to the label; failed to remove the grime from under the dishwasher; failed to clean the fan vent covers in the walk-in refrigerator; failed to remove food buildup from the bread toaster knobs; and failed to ensure the fan closest to the steam table was free from dust on the blades of the fan. This practice potentially affected all residents who ate food from the kitchen. The facility census was 89 residents. 1. Observations on 11/17/24 from 8:50 A.M. through 12:50 P.M., showed: -DA A worked in the the kitchen with his/her hair not completely restrained from 8:50 A.M. through 10:58 A.M. -One bottle of jelly not in the refrigerator label which stated Refrigerate After Opening. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy for tuberculosis (TB-a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) screening annually for five sampled residents (Residents #22, #23, #58, #79, and #56) out of five residents sampled for TB; failed to ensure proper infection control practices were followed in the monitoring of blood glucose levels for five sampled residents (Residents #36, #140, #142, #33, and #143), by not sanitizing a glucometer (machine that measures the amount of blood sugar in a resident's blood) between uses; failed to maintain records of complete screening of new employees for TB for 10 sampled employees (Employee A, B, C, D, E, F, G, H, J, and K) out of 92 new employees; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an influenza (flu) vaccine (an annual vaccine to protect against the influenza virus) was offered to three sampled residents (Residents #22, #23, and #79) and failed to ensure pneumococcal (pneumonia) vaccine (a vaccine to protect against pneumococcal disease caused by the bacteria Streptococcus pneumoniae) was offered, administered or documented five years after a previous pneumonia vaccine for two sampled resident (Resident #23, and #56) out of five residents sampled for immunizations. The facility census was 89 residents. Review of the facility's policy titled Influenza and Pneumococcal Immunizations dated 2023 showed: -All newly admitted residents will be offered to receive the immunizations of influenza and pneumococcal in the facility. -Education was provided at the admitted or agreement time. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the 2024-2025 COVID-19 (a new disease caused by a novel (new) coronavirus) vaccine was offered, administered, or documented for two sampled residents (Resident #23 and #79) out of five residents sampled for immunizations. There were 18 residents in the survey sample. The facility census was 89 residents. Review of the Centers for Disease Control and Prevention (CDC) website dated 10/3/24 showed everyone ages 6 months and older should get a 2024-2025 COVID-19 vaccine. A COVID-19 vaccine policy was requested but not provided by the facility. 1. Review of Resident #23's entry tracking forms showed the resident was originally admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, and interview, the facility failed to ensure the facility's call system was audible at the attendant's area for the residents on the 2nd floor. This practice potentially affected 46 residents who resided on the 2nd floor. The facility census was 89 residents. 1. Observations on 11/18/24 showed: -At 10:04 A.M., there was no audibility (the quality or state of being able to be heard) at the nurse's station, when the call light in resident room [ROOM NUMBER] was activated. -At 10:11 A.M., there was no audibility at the nurse's station when the call light in resident room [ROOM NUMBER] was activated. -At 10:15 A.M., there was no audibility at the nurse's station when the call light in the shower room was activated. -At 10:31 A.M., there was no audibility at the nurse's station when the call light in the whirlpool room was activated. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure there was not a heavy buildup of dust under the vending machines in the second floor dining room and failed to ensure the threshold (a horizontal strip of material that covers the gap between the floor and a door frame) of the door between the carport and the basement entrance was securely affixed to the floor. This practice potentially affected at least 25 residents who used the carport as a smoking area and an unknown number of facility staff who entered the facility through that door. The facility census was 89 residents. 1. Observation on 11/18/24 at 10:39 A.M., showed a heavy buildup of dust under the vending machines in the 2nd floor dining room. During an interview on 11/18/24 at 10:40 A.M., the Maintenance Director said: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident was treated with dignity and respect by not maintaining and enhancing self-esteem, self-worth, and not incorporating individual preferences and choices during assisted feeding for one sampled resident (Resident #56) out of 18 sampled residents. The facility census was 89 residents. Review of the facility's Feeding - Helpless Patient guidelines, undated, showed: -The purpose was to ensure adequate nutrition for those residents who were unable to feed themselves. -Tell the resident they are going to be fed. -If the resident was blind, tell him/her what was being done to feed him/her. -Feed slowly to prevent choking. -Use a straw to give liquids. -When finished wipe the resident's face with a napkin or washcloth. [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct a Criminal Background Check (CBC) and Employee Disqualification List (EDL) check for three sampled employees (Employees D, J and K) and to maintain records of the Social Security number, date of birth , date of employment, experience and education, references and the result of background checks required by section 660.317 of Revised MO Statutes for two employees (Employees J and K) out of 10 employee files requested. The facility census was 89 residents. Review of the Facility's Policy entitled Nursing Home Employee/Personal Records Policy dated 2022 showed: -Policy Statement: The facility is committed to maintaining accurate and confidential employee records, ensuring compliance with all applicable laws and regulations while providing employees with appropriate access to their personal employment information. -Scope: [...]

Inspectors wroteBased on interview and record review, the facility failed to plan, coordinate, and provide a safe and appropriate discharge when the facility initiated an immediate discharge for one sampled resident (Resident #76) out of 36 sampled residents. The resident's discharge notice stated the transfer location was Facility B, however, the resident was transported to the hospital via Emergency Medical Services. Facility B was unaware the resident was to be discharged to them. The facility census was 86 residents. Review of the facility's Discharge and Transfer Resident policy, dated 12/21/24, showed: -The purpose of the policy was to ensure the appropriate procedure for transferring and discharging a resident. -All residents who were discharged out of the facility under any circumstance was given an order from the attending physician. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative(s) of a transfer to a hospital, including the reason for the transfer in writing and failed to provide the Ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) a copy of the notification for two sampled residents (Residents #14 and #30) when sent to the hospital out of 18 sampled residents. The facility census was 89 residents. Review of the facility's Bed-Hold Policy and readmission dated 2021 showed: -At the time of transfer of a resident for hospitalization the facility will provide to the resident and a family member or legal representative written notice. -Notify the family or legal representative and physician about the discharge and reason. [...]

Inspectors wroteBased on interview and record review, the facility failed to allow one sampled resident (Resident #76) to return to the facility after an emergency discharge notice was given to the resident, during the appeal process and once the appeal showed the resident was allowed to return to the facility out of 8 sampled residents. The facility census was 89 residents. Review of the facility's Discharge and Transfer Resident policy, dated 12/21/24, showed the purpose of the policy was to ensure the appropriate procedure for transferring and discharging a resident. In case of involuntary discharge: -The Safety Committee establishes the interventions and implements immediately. -The physician shall be consulted for further interventions. -The assessment and order must be documented in the medical record. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately complete the Resident Assessment Instrument/Minimum Data Set (RAI/MDS-a document which helped nursing home staff gather information on a resident's strengths and needs), which was used to address a resident's individual care plan (a document created for a person that received healthcare, personal care, or other forms of support) when it failed to accurately assess and record the use of bed rails (a rail or board attached to the bed that can reduce the risk of residents rolling, sliding, slipping or falling out of bed and sustaining a serious injury), for one sampled resident (Resident #56) out of 18 sampled residents. The facility census was 89 residents. Review of the facility's RAI Process Protocol Policy, dated 2022, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to review and revise a resident's person-centered care plan (a document created for a person that received healthcare, personal care, or other forms of support) when it failed to ensure resident safety by not addressing the use of bed rails (a rail or board attached to the bed that can reduce the risk of residents rolling, sliding, slipping or falling out of bed and sustaining a serious injury), for one sampled resident (Resident #56) and failed to ensure the resident's care plan was accurate by dating it eight days after the resident discharged from the facility for one sampled resident (Resident #90) out of 18 sampled residents. The facility census was 89 residents. Review of the facility's Policy for Care Plan, dated 2022, showed: -The purpose of the policy was to: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff were smoking in designated smoking areas; and failed to ensure two sampled residents (Resident #50 and #55) were smoking in designated smoking area and not smoking in resident rooms, out of 18 sampled residents. The facility census was 89 residents. Review of the facility's policy, Resident Smoking Policy, dated 5/03/12 showed: -Each resident who smoked would have been reassessed quarterly for the safe smoking capacity. -If a resident began to exhibit unsafe smoking practices, that resident would have been immediately reassessed. -Residents were allowed to smoke at designated times (which were posted and announced). -They were allowed to smoke in designated smoking areas. -The smoking areas were the Day Room on each Resident Care floor and outside of the facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide ongoing communication and collaboration with the dialysis (the process of removing blood from an artery (as of a kidney patient), purifying it by dialysis, adding vital substances, and returning it to a vein) facility regarding dialysis care and services for one sampled resident (Resident #7) out of 18 sampled residents. The facility identified two residents as receiving dialysis. The facility census was 89 residents. Review of the facility's policy titled Policy on Dialysis and Care for the Shunt (a surgically created connection between an artery and a vein that provides access to the bloodstream for dialysis) dated 2023 showed instructions to: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident safety by not following their Restraint Policy and providing bed rails (a rail or board attached to the bed that can reduce the risk of residents rolling, sliding, slipping, or falling out of bed) to one resident (Resident #56) out of 18 sampled residents. The facility census was 89 residents. Review of the facility's Side (Bed) Rail Policy, dated 2024, showed: -Residents with compromised mobility were reassessed upon admission for the use of bed rails. -Residents who used bed rails were screened or assessed monthly according to the monthly assessment schedule. -The care plan reflected the use of bed rails. -The care plan team discussed the use of bed rails during care plan meetings. -The physician was notified of the assessment and recommendations. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that foods stored in the resident use refrigerator was labeled with a resident's name and the date the food was brought in to clearly identify it as a food brought in by visitors and guests. This practice potentially affected at least three residents whose food was stored in the refrigerator. The facility census was 89 residents. Review of the facility's policy entitled Regarding Use and Storage of Foods Brought to Residents by Family and Other Visitors dated 2109, showed: -The facility is responsible for storing food brought in by family or visitors in a way that is either separate or easily distinguishable from facility food. -Clear identify what food has been brought in by visitors for residents and guests when served. 1. Observation on 11/20/24 at 11:38 A.M. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the outdoor dumpster with the lids closed. The facility census was 89 residents. 1. Observation on 11/17/24 at 9:08 A.M. 9:58 A.M. ,and 10:15 A.M., showed the lid of the outdoor dumpster, remained open. 2 Observations on 11/18/24 at 9:49 A.M., 1:27 P.M., 2:06 P.M., and 2:47 P.M., showed the lid of the outdoor dumpster, remained open. 3. Observations on 11/18/24 at 11:20 A.M., and 12:33 P.M., showed the lid of the outdoor dumpster, remained open. During an interview on 11/18/24 at 12:35 P.M., Dietary [NAME] (DC) A said he/she expected facility staff to close the lids after they dump trash. During an interview on 11/18/24 at 12:50 P.M., the Dietary Manager (DM) said he/she expected facility staff to close the lids of the outdoor dumpster.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's care plan was accurate by dating it eight days after the resident discharged from the facility for one sampled resident (Resident #90) out of 18 sampled residents. The facility census was 89 residents. Review of the facility's policy titled Care Plan dated 2019 showed: -The comprehensive care plan was required to be completed within 21 days of admission. -The Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) coordinator follows the Resident Assessment Instrument (RAI - helps the facility staff to gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan) manual to develop the care plan and coordinates the RAI process. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to protect two sampled residents (Resident #1 and #6 ) from physical abuse. On 7/3/24 at approximately 8:10 P.M., Resident #2 who smelled strongly of alcohol entered Resident #6's room and hit him/her in the mouth without provocation, causing a small cut on the resident's lower lip. On 7/22/24 at approximately 9:00 A.M., Resident #2, who smelled strongly of alcohol, became agitated and struck Resident #1 with closed fists in both cheeks approximately one inch below each eye, causing four centimeter cuts requiring a hospital emergency room visit to apply two stitches for each cut out of 10 sampled residents. The resident census was 85 residents. Review of the facility's policy for Abuse and Neglect, revised in 2022 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to report two allegations of resident to resident abuse for two sampled residents (Resident #1 and Resident #6) when on 7/3/24 Resident #2 hit Resident #6 in the mouth causing a small cut on the resident's lower lip and on 7/22/24 Resident #2 hit Resident #6 causing laceration to both sides of his/her cheeks out of 10 sampled residents. The facility census was 85 residents. Record review of the facility's policy for Abuse and Neglect, revised in 2022 showed: -Each resident had the right to be free from abuse. -Abuse was defined as the willful infliction of injury resulting in physical harm, pain or mental anguish, with physical abuse resulting in bodily injury, physical pain, or impairment. Physical abuse included hitting, slapping, punching and kicking. [...]

Inspectors wroteBased on interview and record review, the facility failed to investigate an allegation of resident to resident abuse for one sampled resident (Resident #6 ) when on 7/3/24 Resident #2 entered Resident #6's room and hit him/her in the mouth and cut his/her lip out of 10 sampled residents. The census was 85 residents. Record review of the facility's policy for Abuse and Neglect, revised in 2022 showed: -All allegations of abuse were to have been investigated immediately by facility administrative staff. -The facility was to have investigated who was involved, any injuries sustained, and if the residents needed hospital care. 1. Review of Resident #2's Preadmission Screening and Resident Review (PASRR, DA-124C, a required form to be submitted for any client who requests admission to a Medicaid certified bed regardless of the client's payment source; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate treatment and services to deescalate one sampled resident (Resident #2) out of 10 sampled residents, who was displaying emotional and behavioral adjustment difficulty. The facility census was 85 residents. Record review of the facility's policy for Behavior Management, revised in 2022 showed: -The purpose of the policy was to maintain and promote a healthy environment that provided comfort to the residents. -The policy was also to help the facility staff detect early on, any changes in psychosocial status and appropriate interventions. -The facility staff was to monitor residents with fluctuated behaviors or new behavior symptoms for any underlying medical conditions. -The facility staff was to observe the residents daily and document on the behavioral flow sheet any intensity of behaviors. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide proper notification for an immediate discharge for one sampled resident (Resident #1) out of ten sampled residents. The facility census was 86 residents. Review of the facility's Discharge and Transfer Resident policy, undated, showed: -The purpose of the policy was for transferring and discharging residents. -All residents who discharged out of the facility under any circumstances will have an order from his/her attending physician. -Procedure: --Assess resident condition and determine the needs for transferring or discharging using nursing or professional judgement. --Provide a written instruction with verbal explanation regarding care, treatment, use of medications or devices to the resident or his/her responsible party. [...]

Inspectors wroteBased on interview and record review, the facility failed to plan for discharge for one sampled resident (Resident #1) out of ten sampled residents. The facility census was 86 residents. Review of the facility's Discharge and Transfer Resident policy, undated, showed: -The purpose of the policy was for transferring and discharging residents. -All residents who discharged out of the facility under any circumstances will have an order from his/her attending physician. -Procedure: --Assess resident condition and determine the needs for transferring or discharging using nursing or professional judgement. --Provide a written instruction with verbal explanation regarding care, treatment, use of medications or devices to the resident or his/her responsible party. -Discharge based on disruptive, dangerous, violent behavior that affect the safe living environment. --Examples included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staffing was posted correctly at the beginning of each shift including the census and the total number and actual hours worked per shift which could have the potential to affect all residents in the facility. The facility census was 86 residents. Record review of the facility's policy titled Policy for Staffing dated from 2020 showed the staffing board must be displayed for three shifts in public areas (no name, number of Registered Nurse (RN), Licensed Practical Nurse (LPNs), and Certified Nursing Assistants (CNAs). 1. Observation on 4/14/23 at 9:25 A.M. of the daily staffing sheet on 200 hall showed: -The staffing clipboard was flipped upside down behind the nurse's station. -No census included on the sheet. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a director of food and nutrition services who met the qualifications of a Dietary Manager (DM), was employed since the previous DM left employment at the facility 63 days prior to the start of the survey. This practice potentially affected all residents. The facility census was 86 residents. 1. Observation on 4/10/23 at 8:48 A.M., through 1:22 P.M., showed the absence of a DM from the kitchen. During an interview on 4/10/23 at 9:11 A.M., Dietary [NAME] (DC) A said the previous DM resigned about six to seven months ago. Observations on 4/10/23 from 8:48 A.M. through 1:22 P.M., showed: - A roll of ground meat on a tray without a date that it was taken from the freezer without a date. - Three cutting boards with numerous indentations. - DC A placed bread sticks on pan without gloving his/her hands. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the menu on 4/10/23 by not preparing the meal that was supposed to be prepared on that date according to the Week at a Glance Menu. This practice potentially affected all residents. The facility census was 86 residents. 1. Record review of the Week at a Glance Menu for Week 1 Day 2 showed the following lunch meal: - Mushroom hamburger steak. - Buttered egg noodles. - [NAME] peas. - Cottage cheese with fruit. - Breadstick and beverage. Observation on 4/10/23, showed: - At 10:43 A.M., Dietary [NAME] (DC) A cooked the noodles and placed the noodles in a colander. - At 11:06 A.M., DC A placed frozen packets of chicken soup into a pot for heating. - At 11:10 A.M., DC A placed breadsticks on pan to be placed into the oven for heating. [...]

Inspectors wroteBased on observation and interview, the facility failed to place the date on food that was taken from the freezer and placed into the refrigerator for defrosting; to ensure that all employees wore appropriate hair restraints; to maintain two fans in the kitchen are free from a heavy buildup of dust and one of them from blowing air towards the steam table; to maintain the vent above the steam table free from a buildup of dust; to maintain the shelf above the six burner stove free from a buildup of dust; to maintain the nozzles of the dishwasher spray wands free from debris; to maintain three cutting boards from conditions which made them not easily cleanable; to ensure there were alcohol wipes available to wipe thermometers after use; to ensure Dietary Aide (DA) B washed his/her hands between going from soiled dishes to clean dishes; [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete, accurately documented, and readily accessible, by not providing immunization records for one sampled resident (Resident #30) out of 21 sampled residents and requested policies. The facility census was 86 residents. 1. Requested, verbally to Administrator, on 4/10/23 at 10:09 A.M. the facility's Resident Vaccination Policy. -Requested, in writing to the Administrator, on 4/14/23 at 3:25 P.M. a copy of the facility's Resident Vaccination Policy. -This policy was not received at time of exit. 2. Record review of Resident #30's face sheet showed he/she was admitted with the following diagnoses: -Major Depressive Disorder. -Heart Failure. -Brief Psychotic Disorder. [...]

Inspectors wroteBased on interview and record review, the facility failed to submit the Payroll Based Journal data (PBJ- a report that provides staffing dataset information submitted by nursing homes on a quarterly basis) for the last four quarters which had the potential to affect all residents. The facility census was 86 residents. 1. Record review of the facility PBJ Quarter Two (2022) from 1/1/22-3/31/22 showed no data submitted for the quarter. Record review of the facility PBJ Quarter Three (2022) from 4/1/2022-6/30/22 showed no data submitted for the quarter. Record review of the facilty PBJ Quarter Four (2022) from 7/1/22-9/30/22 showed no data submitted for the quarter. Record review of the facilty PBJ Quarter One (2023) from 10/1/2022-12/31/22 showed no data submitted for the quarter. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide records of all in-services completed within the last 12 months including abuse and neglect training. This had the potential to affect all residents. The facility census was 86 residents. 1. The last 12 months of in-services was requested at the following times: -4/14/23 at 8:54 A.M. -4/17/23 at 9:12 A.M. During an interview on 4/17/23 at 9:47 A.M., Licensed Practical Nurse (LPN) B said: -He/she was unsure if education was provided after a resident-to-resident altercation occurred on 3/28/23. -He/she had received abuse and neglect training sometime last year. -He/she was unsure of other in-service training he/she had in the last year. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess the residents' ability to self-administer medications, monitor for safe administration, monitor storage of self-administered medication, and obtain a physician's order for self-administration of medications for four sampled residents (Resident #80, #77, #59, and #36) out of 21 sampled residents. The facility census was 86 residents. Record review of the facility's policy titled Policy for Non-Prescribing Medications and Self-Administration of Medication, dated 2017, showed: -Staff were to ensure residents that self-administer their own medications had the medications stored in a designated, locked, area in their room. -All bedside medications were to be approved and ordered by the physician. [...]

Inspectors wroteBased on observation and interview, the facility failed to clean the fans in resident rooms 209, 122, 111, 105, 104, and the resident use area of the therapy office; to maintain the ceiling vents in the 2nd floor whirlpool room, resident rooms [ROOM NUMBER]; and to maintain the commode seats in an easily cleanable condition in resident rooms [ROOM NUMBER]. This practice potentially affected at least 25 residents who resided in or used those areas. The facility census was 86 residents. 1. Observation with the Maintenance Director (MD) on 4/11/23, showed: - At 10:06 A.M., a heavy buildup of dust was present on the fan blades in resident room [ROOM NUMBER]. - At 11:40 A.M., a heavy buildup of dust was present on the fan blades resident room [ROOM NUMBER]. - At 12:13 P.M., a heavy buildup of dust was present on the fan blades in the Director of Nursing's (DON's) office. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to complete a thorough investigation of two resident-to-resident physical altercations on 3/28/23 between two supplemental residents (Resident #44 and Resident #82); to complete a timely investigation for a resident to resident altercation between two supplemental residents (Resident #58 and Resident #34), and to document monitoring of the residents after the incident to prevent further altercations out of 21 sampled residents and 14 supplemental residents. The facility census was 86 residents. Record review of the facility's policy titled Policy Regarding Abuse and Neglect of Facility Residents dated from 2020 showed: -All suspected incidents must be investigated immediately. -Report to the charge nurse on duty, which in turn will report to the Administrator or Director of Nursing (DON), and physician. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the bed hold was signed and a copy of the bed hold was retained and provided for two sampled residents (Resident #78 and Resident #16) and one closed record sampled residenet (Resident #86), prior to or upon hospitalization out of 21 sampled residents. The facility census was 86 residents. Record review of the facility ' s policy titled Bed Hold Policy and Readmission dated from 2021 showed: -At the time of transfer of a resident for hospitalization or therapeutic leave, [NAME] Manor will provide to the resident and a family member or legal representative written notice which specifies the duration of the bed-hold policy. -Staff follows the policy to provide this notice when the resident is discharged . 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the care plan was comprehensive, available to the care staff, and addressed five sampled residents' (Resident #19, #72, #30, #59, and #75) health status out of 21 sampled residents. The facility census was 86 residents. 1. Record review of Resident #72's Face Sheet showed he/she was admitted on [DATE], with diagnoses including a left ankle fracture, elevated blood pressure, anxiety, alcohol abuse, depression, sleep apnea (a common disorder in which you have one or more pauses in breathing or shallow breaths while you sleep). Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 1/4/23 showed the resident: -Was alert, oriented and had no confusion. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure results from orthopedic clinic were obtained for one sampled resident (Resident #39) who was seen for follow up for a right arm fracture and to document whether results from the service were provided to the physician; to ensure the administration of a resident's medication by leaving medications at the bedside and unattended by staff and/or residents for four residents (Resident #80, #77, #59, and #36), and to accurately assess a resident's ability to safely smoke for one sampled resident (Resident #80) out of 21 sampled residents. The facility census was 86 residents. 1. Record review of Resident #39's Face Sheet showed he/she was admitted on [DATE], with diagnoses including stroke, high blood pressure, heart disease, and high cholesterol. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store the oxygen nasal cannula/tubing (used to deliver oxygen through the resident's nose), nebulizer mask/mouthpiece (used for aerosol breathing treatments), and bi-level positive airway pressure face mask (bipap-a type of ventilator that helps with breathing) in a manner to prevent the spread of infection for two sampled residents (Resident #77 and #80) and one supplemental resident (Resident #2) out of 21 sampled residents. The facility census was 86 residents. Record review of the facility's policy, dated 10/5/21, titled Policy for Respiratory Care Equipment showed: -For nebulizers, staff were to place in a plastic bag or store in a dust free area. -For face masks and nasal cannulas, staff were to store in a plastic bag labeled with the date and resident's name. [...]

Inspectors wroteBased on observation interview and record review, the facility failed to have enough facility staff available to deliver room trays in an expeditious matter; to maintain the salad at a temperature at or close to 41 ºF (degrees Fahrenheit) and to maintain the chicken noodle at a temperature at or close to 120 ºF at the time of service of the lunch meal test tray. This practice potentially affected at least 6 residents who received their meals closer to the end of the meal delivery service on the 2nd floor. The facility census was 86 residents. 1. Observations on 4/10/23 from 12:04 P.M. through 12:08 P.M., showed the temperatures of the following items in the kitchen, before delivery to the resident floors: -The salad was 50.3 ºF. -The green peas were 203.6 º. -The bread sticks were 158.1 ºF. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain facility records that were readily accessible to include staffing sheets; a record of all staff, including contracted staff, COVID-19 (a new disease caused by a novel (new) coronavirus) vaccinations, and to provide record of any performance reviews completed on Certified Nursing Assistants (CNAs) within the last 12 months. This had the potential to affect all residents. The facility census was 86 residents. 1. Staffing sheets were requested from the Administrator, in writing, on: -4/13/23 at 9:25 A.M. -4/14/23 at 8:54 A.M. -4/17/23 at 9:12 A.M. During an interview on 4/17/23 at 12:55 P.M. the Administrator said: -He/she and Corporate would gather a report that was generated from the time clock data and would send the file to him/her. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide sufficient information that all facility pets were vaccinated. The facility census was 86 residents. Record review of the facility's policy, dated 2012, titled Policy for Pets showed: -All pets were to be up to date with required vaccinations. Record review of City of Kansas City, Missouri-Code of Ordinances, Chapter 14, dated 3/23/23, showed: -Section 14-20 required all residents within Kansas City to procure a license from the commissioner to keep a cat as a pet. -Section 14-24 required a certificate from a licensed veterinarian showing that each animal had been vaccinated against rabies in accordance with Compendium of Animal Rabies Prevention and Control issued annually by the National Association of State Public Health Veterinarians (NASPHV). 1. [...]

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement policies and procedures to ensure all staff were either vaccinated for COVID-19 (a disease caused by a virus names SARS-CoV-2), or had an approved exemption. This failure included the initial and ongoing monitoring for compliance of facility staff vaccination/exemption status. The facility census was 86 residents. Record review of the Center for Disease Control (CDC) Revised Guidance for Staff Vaccination Requirements dated 10/26/22 showed: -Facility staff vaccination rate under 100% constituted non-compliance. -Regardless of clinical responsibility or resident contact, the policies and procedures was required to be applied to facility employees, licensed practitioners, volunteers, and contracted employees. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one supplemental resident (Resident #44) was free from abuse when Resident#82 pushed him/her against the wall of the smoking room with an ashtray pedestal and then pushed him/her into a scale in the hallway resulting in a bruise to his/her hip out of out of 21 sampled residents and 14 supplemental residents. The facility census was 86 residents. Record review of the facility's policy titled Policy Regarding Abuse and Neglect dated from 2020 showed: -Each resident has the right to be free from abuse. -The facility is responsible to prevent abuse. -Residents must not be subjected to abuse by anyone, including other residents. -The suspected victim must be protected immediately by being separated or removed from the suspect. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to report the findings of an investigation of a resident-to-resident physical altercation on 3/28/23 between two supplemental residents (Resident #44 and Resident #82) in which Resident #82 pinned Resident #44 against a wall in the smoking room; and to report an additional altercation between the same supplemental residents (Resident #44 and Resident #82) in which Resident #82 pushed Resident #44 into a scale on 3/28/23 out of 21 sampled residents and 14 supplemental residents. The facility census was 86 residents. Record review of the facility's policy titled Policy Regarding Abuse and Neglect of Facility Residents dated from 2020 showed: -The suspected incident will be investigated immediately. -Division of Health and Senior Services will be contacted if investigation is found valid. [...]

Inspectors wroteBased on interview and record review, the facility failed to incorporate information from the Pre-admission Screening and Resident Review (PASARR) into developing a comprehensive care plan for one sampled resident (Resident #75) out of 21 sampled residents who had a history of mental illness, suicide attempts and arson from his/her distant past. This practice of not developing a care plan based on the information from the PASARR caused facility staff and the Nurse Practitioner (NP) Psychiatrist to not be fully informed about the resident to formulate his/her care. The facility census was 86 residents. 1. Record review of Resident #75's undated face sheet showed he/she was admitted to the facility on [DATE] and had diagnoses which include: -Bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care plans were updated to show the resident's current health status for one sampled resident (Resident #78) out of 21 sampled residents. The facility census was 86 residents. 1. Record review of Resident #78's Face Sheet showed he/she was admitted on [DATE], with diagnoses including high blood pressure, schizophrenia (a severe psychiatric disorder with symptoms of emotional instability, detachment from reality, and withdrawal into the self), diabetes, high potassium, amputation of the left breast, and high cholesterol. Record review of the resident's Care Plan dated 9/11/22, showed the resident had oral/dental health problems related to poor oral hygiene. Interventions showed staff would: -Administer medications as ordered and monitor/document for side effects and effectiveness. [...]

Inspectors wroteBased on interview and record review, the facility failed to regularly reevaluate the discharge plan, involve the resident, address the resident's goals, and document that the resident had been asked about his/her interest in returning to the community for one sampled resident (Resident #77) out of 21 sampled residents. The facility census was 86 residents. Record review of the facility's policy, dated 2023, titled Protocol for Discharge Planning showed: -Residents were to be assessed for discharge potential upon admission, quarterly, and as needed. -Residents were to be assessed at least quarterly for the wish to discharge from the facility. -The Social Services Designee (SSD) was to conduct an interview with the resident and family on admission and quarterly for desire to discharge. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide bathing and nail care assistance for a resident dependant upon staff for those cares for one sampled resident (Resident #12) out of 21 sampled residents. The facility census was 86 residents. Record review of the facility's policy, dated 2021, titled Policy for Daily ADL showed: -Staff were to assist and/or encourage the residents to perform ADLs. -Staff were to follow the care plan for each resident for instructions and preferences with ADL care. 1. Record review of Resident #12's face sheet showed he/she was admitted with the following diagnoses: -Chronic Kidney Disease, Stage 5 (kidneys are severely damaged and have stopped doing their job to filter waste from the blood; waste products may build up in the blood and cause other health problems). [...]

Inspectors wroteBased on interview, and record review, the facility failed to maintain accountability of a controlled substance medication, Xanax (alprazolam is a benzodiazepine (antianxiety) medication used to treat anxiety and panic disorders) and to ensure a safe secure storage of controlled substance medications for one sampled resident (Resident #84) , out of 21 sampled residents. The facility census was 86 residents. Record review of the facility's policy titled Medication Administration and Monitoring, dated 2017, showed: -The nursing professionals and Certified Medication Technicians (CMT) were responsible to ensure accountability of medications during the change over of the shift. Record review of the facility's policy titled Management of Schedule II Medication, dated 2017, showed: -All controlled medication shall be checked and counted each shift by two licensed nursing staff. [...]

Inspectors wroteBased on interview and record review the facility failed to provided physician order anti-anxiety medication as prescribed for one sampled resident (Resident #84), who was without his/her anxiety medication for ten days, out of 21 sampled residents. The facility census was 86 residents. Record review of the facility's policy titled Medication Administration and Monitoring, dated 2017, showed: -Document by circle initials on the Medication Administration Record (MAR) if medication not administered and reason why. -Immediately notify the Director of Nursing (DON) and the resident's physician if not given two days in a row. -The nursing professionals and Certified Medication Technician (CMT) were responsible to ensure accountability of medication during the change over of the shift. Record review of the facility's policy titled Management of Schedule II medication, dated 2017, showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored in a locked compartment for two sampled residents (Resident #80 and Resident #77) out of 21 sampled residents. The facility census was 86 residents. Record review of the facility's policy, dated 2017, titled Policy for Non-Prescribing Medication and Self-Administration of Medication showed: -Residents who self-administered their own medication were to store the medication in a designated, locked, area of their room, or have the medication stored in the facility medication storage area. -Staff were to address placement of medications on the resident's care plan. 1. Record review of Resident #80's face sheet showed he/she was admitted with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD - a disease process that decreases the ability of the lungs to perform ventilation). [...]

Inspectors wroteBased on interview, and record review, the facility failed to assist one sampled resident (Resident #50) in obtaining routine and/or emergency dental care out of 21 sampled residents. The facility census was 86 residents. Record review of the facility's policy, dated 2017, titled Policy for Ancillary Services showed: -Staff were to arrange services for dental services once a recommendation was made for such services by any care provider. -Staff were to obtain a physician's order for dental services once a recommendation was made. -Staff were to arrange for the services to be completed. -Staff were to visit with the resident to address concerns and ensure dental needs were addressed on the care plan. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to include a section in the facility's visitor's food policy regarding labeling food that is brought in to residents by visitors with a date and the resident's name and to store food items (a ham/cheese sandwich, drinks, and sliced bread) with a resident's name and a date that the foods were brought in, in the 2nd floor resident use refrigerator. This practice potentially affected at least two residents who had foods stored in the 2nd floor refrigerator. The facility census was 86 residents. Record review of the facility's policy entitled Policy Regarding Use and Storage of Foods Brought to Residents by Family and Other Visitors dated 2019, showed: - Purpose: To be compliant with regulatory requirement to respect the resident's rights to accept food from outside resources. [...]

Inspectors wroteBased on observation and interview, the facility failed to close the lids of the outdoor dumpster while not in use and failed to close the lid to trash container that was next to the food preparation table, [NAME] it was not in use. This practice potentially affected the outdoor and the kitchen areas. The facility census was 86 residents. 1. Observation on 4/10/23 at 8:49 A.M., 9:52 A.M., 10:21 A.M., and 11:05 A.M., showed the lids of the outdoor dumpster were left open. Observation on 4/10/23 at 11:05 A.M., showed Dietary Aide (DA) B went outside with a bag of trash and placed it in the dumpster and left the lids open. Observation on 4/10/23 at 9:11 A.M., 10:21 A.M., 11:05 A.M., showed the trash container next to the food preparation table was left open. Observation on 4/10/23 at 12:35 P.M., showed the trash from the trash container overflowed onto the food preparation table. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow a physician order for rehabilitative services and to notify the physician in a timely manner that rehabilitative services were not able to be provided for two sampled residents (Resident #39 and #72), so that alternate plans for receiving services could be initiated out of 21 sampled residents. The facility census was 86 residents. 1. Record review of Resident #39's Face Sheet showed he/she was admitted on [DATE], with diagnoses including stroke, high blood pressure, heart disease, and high cholesterol. Record review of the resident's significant change Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 2/28/23 showed the resident: -Was alert and oriented without confusion. [...]

Inspectors wroteBased on interview and record review, the facility failed to offer or administer the pneumonia and influenza vaccine for one closed record sampled resident (Residents #87) out of 21 sampled residents out of five sampled residents for immunizations. The facility census was 86 residents. Resident Vaccination Policy was requested on 4/10/23 at 10:09 A.M. and 4/14/23 at 3:25 P.M., not received at time of exit. Record review of The Center for Disease Control (CDC) webpage, dated 2023, titled Adult Immunization Schedule by Age showed: -The influenza vaccine was to be given annually. -The pneumococcal vaccine was to be given to anyone age [AGE] or older. 1. Record review of Resident #87's admission Minimum Data Set (MDS-a federally mandated tool used for care planning), dated 6/23/22, showed the resident: -Had renal insufficiency (poor function of the kidneys). [...]