Country Club Rehab and Healthcare Center

Inspectors wroteBased on interview, and record review, the facility failed to have a Registered Nurse (RN) at least eight consecutive hours a day for seven days a week. This was evidenced by the facility's documentation indicating RNs were not working in the facility for 11 out of 30 days, from 2/11/25 through 3/11/25. The facility census was 65 residents. 1. Review of the staffing sheet dated 2/12/25 showed there was no RN coverage all day. -Review of the Staffing Sheet dated 2/13/25 showed there was no RN coverage all day. -Review of the Staffing Sheet dated 2/14/25 showed there was no RN coverage all day. -Review of the Staffing Sheet dated 2/16/25 showed there was no RN coverage all day. -Review of the Staffing Sheet dated 2/17/25 showed there was no RN coverage all day. -Review of the Staffing Sheet dated 2/20/25 showed there was no RN coverage all day. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to designate a qualified person to serve as the Director of Food and Nutrition Services. The facility did not employ a qualified Dietitian or other clinically qualified nutrition professional on a full-time basis, The facility census was 65 residents. Review of information titled, Director of Food and Nutrition Services Qualifications, and posted on 2/16/24 by the Missouri Department of Health & Senior Services (https://ltc.health.mo.gov/archives/16528), found the following: -We have recently received in influx of questions related to the qualifications for director of food and nutrition services in skilled nursing facilities. The federal regulation requires one of the following qualifications (if a qualified dietician or other clinically qualified nutrition professional is not employed full-time): [...]

Inspectors wroteBased on interviews, and record review the facility failed to employ sufficient staff to carry out the functions of the Food and Nutrition Service department; and failed to ensure the Dietary Department had received adequate training and/or skills competency verification to ensure they were able to prepare and serve foods to residents in accordance with planned menus and their associated recipes. This deficient practice had the potential to affect 64 of 65 residents who received oral nutrition prepared and served by the facility's dietary department. The facility census was 65 residents. Review of the facility's policy titled Dietary Department - General, revised on 10/24/22, showed: -Policy: The dietary department is responsible for establishing a program that meets the nutritional needs of the residents and accounts for cultural, religious, physical, psychological, and social needs. [...]

Inspectors wroteBased on observation, interview, record review, the facility failed to ensure meals were prepared in accordance with planned menus approved by the Consultant Dietitian using the corresponding recipes for the menu items, which resulted in foods not being attractive and palatable when served. This deficient practice had the potential to affect 64 of 65 residents who received oral nutrition prepared and served by the facility's dietary department. The facility census was 65 residents. Review of the facility's policy titled Dietary Department - General, revised on 10/24/22, showed: -Policy: The dietary department is responsible for establishing a program that meets the nutritional needs of the residents and accounts for cultural, religious, physical, psychological, and social needs. -The primary objectives of the dietary department include: [...]

Inspectors wroteBased on observation, interview, record review and performance of test trays to evaluate the quality of foods at the point of service, the facility failed to develop and implement a process for ensuring residents received foods that were flavorful, palatable, attractive, and at a safe and appetizing temperature. The facility census was 65 residents. Review of the facility's policy titled, Dietary Department - General, revised on 10/24/22, found: -The dietary department is responsible for establishing a program that meets the nutritional needs of the residents and accounts for cultural, religious, physical, psychological, and social needs. -The primary objectives of the dietary department include: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff working in the kitchen effectively restrained their hair, including facial hair, to prevent contamination of food during food preparation and service; failed to ensure staff performed hand hygiene and used single-use gloves appropriately for food safety; failed to prepare and serve foods under sanitary conditions; failed to store Time and Temperature Control for Safety (TCS) foods in refrigerators within the appropriate temperature range to promote safety; failed to routinely monitor and record food temperatures when held on the steam table prior to service; and failed to routinely monitor and record the concentration of the sanitizing solutions used in the low temperature dish machine and in the three-compartment pots and pans sink. The facility census was 65 residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat residents with respect and dignity during dining observations, call bell response, and during the provision of care and treatment for six sampled residents (Resident #263, #50, # 264, #12, #30, and #43) out of 29 sampled residents reviewed for dignity and respect. The facility census was 65 residents. Review of the facility's policy titled, Privacy and Dignity, dated October 24, 2022, showed: Purpose: To ensure that care and services provided by the Facility promote and/or enhance privacy, dignity, and overall quality of life. Policy: The facility promotes resident care in manner and an environment that maintains or enhances dignity and respect, full recognition of each resident's individuality. Procedure: I. Staff assists the resident in maintaining self-esteem and self-worth. II. [...]

Inspectors wroteBased on observation and interview, the facility failed to close and lock the shower doors on the 200, 300 and 400 Halls to prevent high risk wandering residents from hazardous accidents for 13 wandering residents. The facility census was 65 residents. A request was made of the facility for policies and procedures addressing the storage of chemicals. No such policies or procedures were provided prior to the exit. 1. Observation on 3/12/25 at 10:00 A.M. showed: -The door to the shower room on the 200 Hall unit was opened and exposed multiple areas within the shower room. -Multiple body washes, shampoos and conditioners, anti-perspirants/deodorant, and a bottle of hair spray. -There was a four door storage cabinet. Each door was equipped with a key-lock cabinet for staff to lock all items in the shower room. Observation on 3/12/25 at 10:15 A.M. showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that a Quality Assurance and Performance Improvement (QAPI) Plan was in place to ensure the facility's care delivery system was consistent and accurate and did not identify concerns within the facility system and ensure a plan was in place to ensure improvement. This affected all residents. The facility census was 65 residents. A review of the facility's policy and procedure titled, QAPI Program, dated 10/24/22, showed: -Purpose: To ensure that all services provided by the facility to resident meet quality standards. -The Facility implements and maintains an ongoing, Facility-wide Quality Assurance and Performance Improvement (QAA) Program designed to monitor and evaluate the quality of resident care, pursue methods to improve care quality, and resolve identified problems. -Procedure: 1. Goals: A. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections by not ensuring staff transported residents food down each hall in a manner to prevent cross-contamination; failed to ensure supplements and disposable equipment used during the administration of enteral nutrition were labeled, dated, and/or discarded when indicated and stored in a safe and sanitary manner between uses for two sampled residents (Resident #43 and #6); out of two sampled residents who received enteral nutrition; failed ensure personal hygiene products and care equipment (e.g., roll-on deodorant, combs, etc.) stored in the 400 Hall shower room were not available for common use to the 17 residents residing on this hall. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a wheelchair available for common use was maintained in a safe and sanitary manner. This deficient practice had the potential to affect any of the 17 residents residing on 400 hall who may have required wheelchair assistance. The facility census was 65 residents. A review of the facility policy titled Infection Prevention and Control Program, revised 10/24/22, showed: -Purpose: To ensure the Facility establishes and maintains an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with Federal and State requirements. [...]

Inspectors wroteBased on interview, and record review, the facility failed to follow physician's orders for treatments and to document the resident's pressure ulcers, for one sampled resident (Resident # 3) out of six sampled residents. The facility census was 61 residents. On 10/15/24 the Administrator and acting Director of Nursing (DON) were notified of past non-compliance which occurred on 7/30/24. On 7/30/24 the facility Administrator was notified of the Wound Nurse was not signing off treatment orders and not completing documentation as expected. Wound Nurse A was assigned a floor position, and wound duties were assigned to the Assistant Director of Nursing (ADON) on 8/8/24. No nurses were allowed to provide wound care prior to reeducation completed 7/30/24. The deficiency was corrected on 7/30/24. Review of the facility Wound Management Policy dated 10/24/22 showed: [...]

Inspectors wroteBased on interview, and record review, the facility failed to follow physician's orders for skin treatments and to document the treatments in the medical record for one sampled resident (Resident #3) out of six sampled residents. The facility census was 61 residents. On 10/15/24 the Administrator and acting Director of Nursing (DON) were notified of past non-compliance which occurred on 7/30/24. On 7/30/24 the facility Administrator was notified the Wound Nurse was not signing off treatment orders and not completing documentation as expected. Wound Nurse A was assigned a floor position, and wound duties were assigned to the Assistant Director of Nursing (ADON) on 8/8/24. No nurses were allowed to provide wound care prior to reeducation completed 7/30/24. The deficiency was corrected on 7/30/24. Review of the facility Wound Management Policy dated 10/24/22 showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to have an Infection Preventionist, maintain proper use of Personal Protective Equipment (PPE) and adhere to isolation precautions during a COVID-19 (is an infectious disease caused by the SARS-CoV-2 virus) facility outbreak placing potentially all residents at risk for exposure. The facility census was 65 residents. Review of the facility COVID 19 Testing Infection Control Manual dated 5/16/23 showed: -Purpose: --To prevent COVID 19 from entering nursing homes, detect cases quickly, and stop transmission. -Policy: --The facility will test resident and facility staff, including individuals providing services under arrangement and volunteers for COVID 19 in accordance with the current guidelines required by state and federal oversight agencies. [...]

Inspectors wroteBased on observation and interview, the facility failed to serve the lunch meal in a timely manner, according to the facility posted schedule. This practice potentially affected all residents. The facility census was 62 residents. 1. Observation on 10/30/23 at 10:46 A.M., of the posted meal times showed the lunch meal was to be served between 11:30 A.M. and 12:30 P.M. Observation on 10/30/23 during the lunch meal preparation showed: - At 11:21 A.M., Dietary [NAME] (DC) A made pureed (food that was made into a paste or thick liquid suspension that was usually made from cooked food that was ground finely) rice. - At 11:30 A.M. (the time that lunch should be served), DC A washed the food processor container to puree another item (vegetables). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the recipe for pureed (food that was made into a paste or thick liquid suspension that was usually made from cooked food that was ground finely) rice which resulted in a bland taste for the pureed rice and the facility failed to check the temperature of plates which contained pureed vegetables, pureed meat and pureed rice which were placed on the plates and the plates were not kept at a temperature of 120 ºF (degrees Fahrenheit) or greater. This practice potentially affected 4 residents who required pureed food out of 9 sampled residents. The facility census was 62 residents. 1. Review of the undated recipe for five servings of pureed rice showed: -2 ½ cups of rice. -2 Tablespoons (Tbsp) margarine. -1 ½ cups of water. -1 teaspoon (tsp) chicken base. Observation on 10/30/23 at 11:21 A.M., showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that two sampled residents (Residents #6 and #8) out of 9 sampled residents, received their preferred items during their meals. The facility census was 62 residents. 1. Review of Resident #6's quarterly Minimum Data Set (MDS -a resident a federally mandated assessment tool completed by the facility for care planning), dated 8/23/23, showed: - The resident was cognitively intact. - A resident who was able to make himself/herself understood and understood others. - A resident who had no symptoms of swallowing disorders. During an interview on 10/30/23 at 11:08 A.M., the resident said: - He/She filled out a survey and selected his/her likes and dislikes. - He/She did not always get what they order on the ticket or what he/she selected. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure coordination of care was completed for one sampled resident (Resident #72) who missed a hemodialysis (dialysis a procedure involving diverting blood into an external machine, where it is filtered before being returned to the body to remove waste products and excess fluid from the blood when the kidneys stop working properly) treatment resulting in an emergency hospitalization out of 19 sampled residents. The facility census was 66 residents. Review of the facility's policy titled Dialysis Care dated 10/24/22 showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the staffing was posted and posted correctly to include the total census of the facility. The facility census was 66 residents. Review of the facility's policy titled Nursing Department-Staffing, Scheduling, and Postings dated 10/24/22 showed: -The facility will post the following information on a daily basis: --Facility name. --The current date. --The total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift including Registered Nurses (RN's), Licensed Practical Nurses (LPN's), and Certified Nursing Assistants (CNA's). --Resident census. -The facility will post the nurse staffing data specified above on a daily basis at the beginning of each shift. [...]

Inspectors wroteBased on observation and interview, the facility failed to place the date that a tray of ground meat rolls and a box of hamburger patties, were taken from the freezer for defrosting; to label two containers of liquids with the substance that was in those containers; to label three containers of a white powdery substance, with the actual substance that was in those containers; to ensure three cutting boards were maintained without numerous indentations and grooves; to ensure the floor under the dishwasher was free from grime and debris buildup; to thoroughly wash the food processor between using the food processor to grind different items of food; and to ensure one Dietary Aide (DA) A washed or sanitized his/her hands between handling soiled dishes and clean dishes. This practice potentially affected 65 residents who ate food from the kitchen. The facility census was 66 residents. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure handwashing was done to prevent cross contamination during incontinence care for two sampled residents (Resident #56 and #10); to ensure proper cleaning of shower chair before use for one sampled resident (Resident #39), to have an Infection Surveillance Program that included adequate documentation and monitoring for all residents infections; to ensure proper hand hygiene was completed during a transfer with a sit-to-stand lift (an assistive device used to aide a person in transfer who can still bear weight to the lower extremities) and perineal care for one supplemental resident (Resident #2); to ensure staff wore gloves while handling a medicated patch that was absorbed through the skin for one sampled resident (Resident #72); [...]

Inspectors wroteBased on interview and record review, the facility failed to keep records of receipts of transactions for three residents (Residents #22, #28 and #32) out of four residents sampled for the purpose of reviewing resident trust fund procedures. The facility census was 66 residents. 1. Review of Resident #22's resident trust fund transactions dated 4/23 to 7/23 showed a withdrawal of $17.00 on 4/14/23 for a beauty shop appointment. Review of the transaction book showed the absence of a resident signature for that withdrawal or a receipt to show that amount was withdrawn on the resident's behalf. During an interview on 8/7/23 at 2:04 P.M., the Business Office Manager (BOM) said he/she did not see a receipt for the 4/14/23 transaction. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow facility policies and procedures for checking the Nurse Aide Registry (NAR) and the Criminal Background Check (CBC) as part of the background check for all newly hired employees, within a timely manner and in accordance with state requirements prior to employing four of 10 employees sampled for the criminal background screening. The facility census was 66 residents. Review of the facility's Abuse and Neglect policy and procedure updated 10/24/22, showed the facility does not knowingly employee anyone who has had disciplinary action against his/her professional license, or a finding entered into the state nurse aide registry related to abuse, neglect, mistreatment, or misappropriation, or has been convicted of abusing, neglecting or mistreating other people. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the treatment carts on 300 and 400 hall, and medication cart on 200 hall remained locked when not in use and not within eyesight. The facility census was 66 residents. Review of the facility's policy, titled Medication Storage dated January 2021, showed: -The facility was to ensure medication was accessible only to licensed nursing personnel, pharmacy personnel, or staff members that were lawfully authorized to administer medicine. -Medication rooms, cabinets, and medical supplies were to remain locked when not in use unless attended by a person with authorized access. 1. Observation on 8/6/23 at 4:59 P.M. showed: -The facility's crash cart (a cart containing equipment for use in an emergency) had the lock removed and sitting inside the cart. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assess the dietary preferences of three sampled residents (Residents #16, #17, and #71) by not doing a dietary profile and to ensure food substitutes which were consistent with ordinary food items which were provided by the facility, were available for residents who did not prefer to eat the items which were offered. The facility census was 66 residents. 1. Review of Resident #16's face sheet showed he/she admitted with the following diagnoses: -Generalized muscle weakness. -Unspecified heart failure. -Type 2 diabetes mellitus (a group of diseases that affect how the body uses blood sugar (glucose). -High blood cholesterol (when you have too much of a fatty substance called cholesterol in your blood). [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the restroom ceiling vents in resident rooms 110, 103, 101 in the 100 Hall, had negative air flow. This practice potentially affected at least 10 residents who resided in those rooms. The facility census was 66 residents. Note: Air flow was tested by holding one piece of tissue paper to the ceiling vent. If the paper was sucked up, then negative air flow was present; if the paper fell to the floor, then negative airflow was absent. 1. Observation on 8/8/23, with the Maintenance Assistant showed: -At 1:40 P.M., a tissue paper was held up to the restroom ceiling vent in resident room [ROOM NUMBER] and the tissue paper was not held and it fell to the floor. -At 1:50 P.M., a tissue paper was held up to the restroom ceiling vent in resident room [ROOM NUMBER] and the tissue paper was not held and it fell to the floor. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the following attic areas free of animal droppings: the front hall mechanical room access, the therapy area attic access, the 300 Hall attic access; failed to remove remnant hay from the attic area over the 400 Hall; and to ensure the area between the bed and wall in resident room [ROOM NUMBER], was free of dead insects and cobwebs. This practice potentially affected at least 40 residents who resided in those areas. The facility census was 66 residents. 1. Observation on 8/7/23, with the Maintenance Assistant showed the following: -At 9:58 A.M., there was a pile of animal droppings in one corner of the attic area over the front hall mechanical room. -At 10:22 A.M., there was a pile of animal droppings in one corner of the attic over the therapy area. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide supporting documentation for the use of a resident monitoring system/bracelet (a bracelet securely attached to a resident that electronically notified the facility when the resident attempted to leave the ward or unit to which the resident was assigned) safety device to include changes in the resident's behavior or exit seeking behaviors for one sampled resident (Resident #35) out of 19 sampled residents. The facility census was 66 residents. Review of the facility's policy, dated October 24, 2022, titled Restraints showed: -The facility was to provide an environment that was restraint-free unless a restraint was necessary to treat a medical symptom, in which case the least restrictive measure was to be used. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the balance of resident funds were forwarded to two discharged residents (Residents #75 and #76) out of three discharged residents, reviewed for the business office processes, within five days of their discharge. The facility also failed to inform the new Business Office Manager (BOM) about the regulatory requirements which pertained to the Business Office procedures. The facility census was 66 residents. 1. Review of Resident #75's medical record showed: -The resident was discharged from the facility on 3/27/23. -The resident had $66.00 in his/her account the day he/she left the facility. During an interview on 8/7/23 at 2:36 P.M., the BOM said: -He/she took over the BOM duties in June 2023. -He/she had to close out a few accounts when he/she became the BOM. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure wound treatment orders were complete on the physician's order sheet; to ensure the wound vacuum (wound vac a device that uses negative pressure to help heal wounds due to the negative pressure created by the wound vac pulls fluid and infection out of the wound, encouraging the wound to heal faster) was stored to prevent cross contamination; and to include care plan interventions for wound care for one sampled resident (Resident #175); and to effectively communicate and educate the reason for Enhanced Barrier Precautions (EBP-is an approach of targeted gown and glove use during high contact resident care activities, designed to reduce transmission of S. aureus and Multiple Drug Resistant Organism (MDRO) for one sampled resident (Resident #6) out of 19 sampled residents. The facility census was 66 residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain wound treatment orders to the resident's heel and apply physician ordered treatment for one sampled resident (Resident #56) who was readmitted to the facility with open areas to his/her buttock out of 19 sampled residents. The facility census was 66 residents. 1. Review of Resident #56's Face Sheet showed he/she was admitted on [DATE], with diagnoses including urinary tract infection, muscle weakness, pain, heart failure, low iron, high blood pressure, arthritis, edema (fluid in the tissues), fall history, and pressure sores (areas of damage to your skin and the tissue underneath from prolonged pressure on the skin). Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 5/1/23, showed the resident: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately complete a comprehensive fall investigation that included root cause and preventive interventions; to accurately document the resident's fall status on the Minimum Data Set (MDS, a federally mandated assessment tool to be completed by facility staff for care planning); to update the resident's care plan to show the preventive interventions after the fall for one sampled resident (Resident #53); and to ensure a safe mechanical lift transfer by not ensuring wheelchair brakes were locked for one sampled resident (Resident #10) out of 19 sampled residents. The facility census was 66 residents. Review of the facility's Fall policy and procedure dated 10/24/22, showed: -Following each resident fall, the licensed nurse will complete an incident report and perform a post fall assessment and investigation. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain a physician's order for self-administration of catheter (a thin, flexible catheter used especially to drain urine from the bladder by way of the urethra) care; to assess the resident's ability and capacity for self-care of his/her catheter; and to update the care plan for one sampled resident (Resident #69), out of 19 sampled residents. The facility census was 66 residents. Review of the facility's Catheter policy and procedure dated 10/24/22, showed each resident who was incontinent of urine was identified, assessed and provided appropriate treatment and services to achieve or maintain as much normal urinary function as possible; a resident with or without a catheter, received the appropriate care and services to prevent infections to the extent possible. Regarding daily care it showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure weight loss was reviewed, dietary recommendations were put into place, the physician was notified of weight loss, and the care plan was accurate and reflected the resident's current health status for two sampled residents (Resident #6 and #39); the facility failed to provide alternative meal menu to bed bound residents and ensure to monitor food preference for one sampled resident (Resident #39) who was at risk for weight loss and diabetic ketoacidosis coma (a serious condition that can lead to diabetic coma or even death) out of 19 sampled residents. The facility census was 66 residents. Review of the facility's policy, titled Assessment and Management of Resident Weights dated October 22, 2022, showed: -Staff were to obtain weights upon admission and readmission, weekly for four weeks, then monthly. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store and replace the oxygen nasal cannula/tubing (used to deliver oxygen through the resident's nose) and nebulizer mask/tubing (used for aerosol breathing treatments) and humidifiers (adds water to the oxygen to prevent dryness, used for resident comfort) in a manner to prevent the spread of infection for one sampled resident (Resident #6) and two supplemental residents (Resident #34 and #63) out of 19 sampled residents and 10 supplemental residents. The facility census was 66 residents. Review of the facility's policy, titled Oxygen Administration dated 10/24/22, showed all oxygen tubing, humidifiers, masks, and nasal cannulas used to deliver oxygen: -Were to be changed weekly. -Were to be stored in a plastic bag to protect the equipment from dust and dirt when not in use. [...]

Inspectors wrote2. Review of Resident #49's face sheet showed he/she admitted to the facility with the following diagnoses: -Unspecified Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses). -Bipolar Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). -Mood Disorder due to known Psychological Condition. Review of the resident's Treatment Administration Record (TAR) dated July 2023 showed the resident exhibited anti-psychotic medication side effects at the following times: -On 7/6/23 during the day shift. -On 7/7/23 during the day shift. -On 7/13/23 during the day shift. -On 7/14/23 during the day shift. -On 7/20/23 during the day shift. [...]

Inspectors wroteBased on interview and record review, the facility failed to update the facility assessment annually and as needed and to ensure COVID 19 (a new disease caused by a novel (new) coronavirus) information was included in the assessment to determine resources necessary to meet the needs of the residents. The facility census was 53 residents. A policy for the Facility Assessment was requested and not provided. 1. Record review of facilities Facility assessment dated [DATE] showed: -It had not been updated. -It did not identify the needed space, equipment, assisted technology, communication devices, or other material resources that were needed to provide the required care and services to the residents. -It did not include an evaluation of the overall number of facility staff needed to ensure a sufficient number of qualified staff were available to meet the resident's needs. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to use appropriate infection control procedures to prevent cross-contamination during blood glucose testing when staff did not clean the glucometer correctly, use barrier and sat glucometer on resident use items for six sampled residents (Residents #32, #8, #25, #30, #4, and #42); facility failed to use acceptable infection control measures while providing wound care when staff did not sanitize scissors, put supplies on surfaces without barriers, and did not perform hand hygiene between glove changes for two sampled residents (Resident #22 and #20) out of 15 sampled residents; [...]

Inspectors wroteBased on interview and record review, the facility failed to distribute interest (money paid regularly to depositors of money at a financial institution a particular rate) for residents who allowed the facility to manage their resident funds during the months of December 2021 and January 2022. This practice potentially affected 11 residents who allowed the facility to manage their funds. The facility census was 53 residents. 1. Record review of the facility's trust Transaction History dated December 2021 and January 2022, showed no interest was paid for residents in December 2021 and in January 2022. During an interview on 2/16/22 10:29 A.M., the Business Office Manager (BOM) said: - Without bank statements (which were not available to the BOM until February 17, 2022) it was difficult to determine what amount of interest should have been paid to residents in 12/2021 and 1/2022. [...]

Inspectors wroteBased on interview and record review, the facility failed to procure reconciled (a process that takes place when the deposits, credits and interest that are on record but were not accounted for on the final bank statement, are added to the final amount on the bank statement, then checks and charges that are on record, but were not listed on the bank account statement, are subtracted from the adjusted final amount) bank statements for the months of December 2021 and January 2022. This practice potentially affected 11 residents who allowed the facility to manage their funds in the resident trust system. The facility also failed to maintain a record of any receipt that would have been given to the entity for two deposits of $100.00 each into the account of one resident (Resident #30) on 12/8/21. The facility census was 53 residents. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to submit the new bond (an insurance agreement pledging that one entity will become legally liable for financial loss caused to another by the act or default of a third person) for approval to the Division of Regulation and Licensure (DRL). This practice potentially affected 11 residents who have allowed the facility to manage their resident funds. The facility census was 53 residents. 1. Record review of the Bond Rider dated 1/1/22, showed: - The effective date was 1/1/22. - A signed statement which stated: Bond Insurance Company A has caused this instrument to be signed by its duly authorized Attorney-in Fact (a person who is authorized to act on behalf of another person, usually to perform business or other official transactions) on 12/21/21. Record review of the Nursing Home Surety Bond dated 1/1/22 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three prospective applicants for employment (Employees # 1, #6 and #7) out of 10 sampled new employees had documented proof of a Federal Indicator Check through the Nurse Aide (NA) Registry prior to employment and to specify in their Employment Screening policy that all prospective employees, not just those applying for the position of Nurse Assistant or Certified Nursing Assistant (CNA), would require a Federal Indicator Check through the NA Registry. The facility census was 53 residents. Record review of the facility's Employment Screening policy, revised 2/20/15 showed: -In accordance with State and Federal regulations this facility will not knowingly hire, contract or retain any individual that is ineligible to work in a healthcare facility or excluded from participation in the Medicare or Medicaid program. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure bathing was completed per preferences to keep three sampled residents (Resident #12, #30, and #25) clean and odor free out of 15 sampled residents. The facility census was 53 residents. Record review of the facility's Shower/Tub Bath policy revised 10/2010 showed: -The purpose of this procedure was to promote cleanliness, provide comfort, and observe the residents' skin condition. -The staff should document the date and time the shower/tub bath was performed. -All assessment data of the residents' skin observed during the shower. -If the resident refused the bath and reason. -The signature and title of the person recording the data. -Notify the supervisor if the resident refused a shower/tub bath. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor a resident's pressure injury (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) by failing to complete weekly skin and/or wound assessments for three sampled residents (Residents #22, #20, and #35) out of 15 sampled residents. The facility census was 53 residents. Record review of the facility's Prevention of Pressure Injury policy dated September 2013 showed: -The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family, and addressed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete urinary catheter (a tube passed through the urethra into the bladder to drain urine) care each shift as ordered by the resident's physician resulting in the resident with a history of Urinary Tract Infections (UTI - an infection in one or more of structures in the urinary system) developing a UTI; failed to ensure the urine graduate was clean, replaced in a timely fashion and placed on a barrier, for one sampled resident (Resident #22); failed to ensure urinary catheter care was provided according to standards of practice for two sampled residents (Residents #22 and #38), and failed to ensure one sampled resident (Resident #25) received incontinence care using hand hygiene to prevent urinary tract infection, out of 15 sampled residents. The facility census was 53 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain a Bureau of Narcotics and Dangerous Drugs license after a change of ownership. This had the potential to affect all residents who used controlled substances (a drug or other substance that is tightly controlled by the government because it may be abused or cause addiction), and to ensure the controlled medications were counted and documented at the beginning of each shift and at the end of each shift to ensure the accuracy of the distribution and use of the controlled medications. This had the potential to affect all residents who used controlled medications in the facility. The facility census was 53 residents. A policy was requested related to controlled substance license but was not received by the facility. Narcotic shift change policy requested but not received by the facility as of 2/16/22. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the kitchen floors under the food preparation table, the ice machine and the floors in the dry goods storage are free of grime and food debris; failed to label dry food storage containers with foods that were not easily identifiable with the name of that food; failed to discard boiled eggs that had been in the walk-in refrigerator for more than seven days; failed to maintain the juice machine free of mold in the inner parts of the juice machine; failed to ensure there was an air gap (is the unobstructed vertical space between the water outlet and the flood level of a fixture) between the drainage hose from the ice machine and the floor drain underneath the ice machine to prevent accidental backflow; [...]

Inspectors wroteBased on interview and record review, the facility failed to update written contracts for the use of outside resources after a change of ownership occurred. The facility census was 53 residents. A policy was requested related to use of outside resources and the facility did not have a policy related to this. 1. Record review of the facility's Report of Change form from the Missouri Department of Health and Senior Services (DHSS) dated 1/10/22 showed: -The facility had a change of ownership on 1/1/22. -A change of operator was effective 1/1/22. -The new operator was a limited liability company. Record review of the Dialysis Services Agreement showed: -A contract for dialysis (dialysis (process of cleansing the blood by passing it through a special machine - necessary when the kidneys are not able to filter the blood) services. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the overhangs in the attic areas of over 300 and 400 Hall free of opening that could let pests in. This practice potentially affected 31 residents who resided in the 300 and 400 halls. The facility census was 53 residents. 1. Observations with the Maintenance Director on 2/14/22, showed: -At 11:04 A.M., an opening was that was 41 inches (in.) long and about 3 in. wide, present opening at the 400 Hall attic area overhang, that could potentially let pests in and two birds' nests were present in the 400 hall overhang area. -At 11:18 A.M., two openings that were 41 in. long and about 3 in. long that could lest pests in, were present at the overhang are of 300 Hall. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure periodic education and evaluation for one sampled resident's (Resident #17) ability to self-administer insulin (injections of the hormone that regulates blood sugar levels) and Accu-Checks (blood sugar meter which measures blood sugar via inserted one-time-use strips - a lancet, i.e. a sharp device is used to prick a finger in order to allow a small amount of blood to be placed onto the strip in the monitor onto which a small amount of blood is squeezed after pricking a finger with a sharp device) out of 15 sampled residents. The facility census was 53 residents. Record review of the facility's Self-Administration policy, revised December 2016 showed: [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain stand up lift A without a crack in the base that a resident would stand up on and to maintain stand-up lift B without a buildup of grime and debris on the base. This practice potentially affected three residents in the facility who depend on stand-up lifts for transfers. The facility census was 53 residents. 1. Observation with the Maintenance Director on 2/14/22 at 1:25 P.M., showed a 2 inch crack that was present in the base of the stand-up lift A. During an interview on 2/14/22 a 1:26 P.M., the Maintenance Director said he/she did not know who was in charge of ordering parts for the stand-up lift. During an interview on 2/14/22 at 3:13 P.M., Certified Nursing Assistant (CNA) C said he/she used the lift earlier that day and did not notice the crack. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately complete a significant change Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) assessment when the resident had a change in condition and was admitted to hospice services (a type of health care for end of life care) for two sampled residents (Resident #22 and Resident #24) out of 15 sampled residents. The facility census was 53 residents. Record review of the facility's policy Electronic Transmission of the MDS revised September 2010 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide discharge planning including disposition of belongings and medications for one closed record resident (Resident #56) out of one closed record sampled. The facility census was 53 residents. 1. Record review of Resident #56's admission Record showed he/she was admitted to the facility on [DATE] for short-term rehabilitation services after a hospital stay for a knee replacement. Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning) dated 11/18/21 showed the resident: -Was admitted to the facility on [DATE] for rehabilitation services. -Was returning to his/her home in the community after his/her rehabilitation services were completed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform a safe transfer when the Certified Nursing Assistant (CNA) pulled a resident up by his/her pants to transfer the resident from a chair to a wheelchair for one sampled resident (Resident #24) who was at risk for falls out of 15 sampled residents. The facility census was 53 residents. Record review of the facility's Safe Lifting and Movement of Residents Policy revised December 2013 showed: -Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding safe lifting and moving of residents. -Manual lifting of resident shall be eliminated when feasible. -Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the medication administration error rate was less than five percent (%). Two medication errors involving insulin (a hormone that helps glucose get into cells for energy) were detected out of 27 opportunities, resulting in a medication error rate of 7.41% affecting two sampled residents (Residents #25 and #42). The facility census was 53 residents. Record review of the facility's policy titled Insulin Administration dated September 2014 showed: -The type of insulin, dosage requirements, strength, and method of administration must be must be verified before administration. -The nurse shall notify the Director of Nursing (DON) Services and Attending Physician of any discrepancies. Review of medlineplus.gov shows approved subcutaneous (beneath the skin) injection sites were listed as: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a significant medication error did not occur during the administration of insulin by administering the incorrect insulin, not providing food or beverage within 15 minutes of insulin administration, and/or administering insulin through the incorrect route for two sampled residents during the medication pass (Residents #25 and #42). The facility census was 53 residents. Record review of the facility's policy titled Insulin Administration dated September 2014 showed: -The type of insulin, dosage requirements, strength, and method of administration must be must be verified before administration. -The nurse shall notify the Director of Nursing (DON) Services and Attending Physician of any discrepancies. Review of medlineplus.gov shows approved subcutaneous (beneath the skin) injection sites were listed as: [...]