Creve Coeur Manor

Inspectors wroteBased on interview and record review, the facility failed to ensure staff assessed and monitored one resident (Resident #3) identified as at risk for developing pressure ulcers (injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or friction). When staff from an outside hospice agency identified a new skin issue and notified the facility nurse, the nurse failed to document the notification and failed to notify the physician timely, resulting in a delay in treatment. Two residents were sampled for pressure ulcers and problems were found with one. The sample was 6. The census was 73. Review of the facility's Wound Management policy, dated 01/2023, showed the following:-Policy: Manage skin integrity through prevention, assessment, and implementation and evaluation of interventions;-Procedure:-The facility is provided with wound care protocols. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff transcribed physician orders and administered medications as ordered for one resident (Resident #1) and to hold medication in accordance with parameters ordered by the physician for one resident (Resident #2). The sample was 3. The census was 79. Review of the facility's Physician's Orders policy, dated February 2020, showed the following:-Elements of the medication order: Name of the medication, strength of the medication, dosage, time or frequency of administration ,route of administration if other than oral, quantity or duration (length) of therapy, diagnosis or indication, medication allergy;-Documentation of the medication order:-1. The physician's new orders may be received on the admission Physician's Order Form, by telephone or handwritten on the Physician Order Sheet (POS). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident received gastrostomy tube (g-tube, a sterile tube surgically inserted through the abdomen into the stomach, used to provide nutrition and fluids) feedings and fluids as ordered. The facility identified three residents with tube feedings, one of whom was sampled and problems were found (Resident #1). The census was 80. Review of the facility's Tube Feeding, policy, dated 3/28/25, showed the following:-Policy: It is the policy of the facility of the facility that residents' nutritional needs will be met by tube feeding, when oral consumption is not possible and the resident consents;-Procedure included:--Check the physician's order to determine type and rate of feeding;--Set the pump for the rate ordered;--Start the pump. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow acceptable infection control standards by not implementing Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) that employs targeted gown and glove use during high contact resident care activities as recommended by the Centers for Disease Control and Prevention (CDC) and required by the Centers for Medicare and Medicaid Services (CMS)), for four residents who required EBP for wound treatment or a medically inserted device (urinary catheter, a sterile tube inserted into the bladder through the urinary tract to drain urine). The facility identified eleven residents requiring EBP, four residents were sampled and problems were found with all four residents (Residents #1, #2, #4, and #5). The census was 77. [...]

Inspectors wroteBased on observations and interviews, the facility failed to use the services of a registered nurse on duty at least eight hours daily. The RN passing medications on dates listed below was also serving as the Director of Nursing while the facility had an average daily occupancy of 68 residents.

Inspectors wroteBased on job description review and interview, the facility failed to ensure that the Dietary Manager (DM) met minimum qualifications when a Registered Dietician (RD) was not employed full time at the facility. The deficient practice has the potential to affect all 69 residents who receive food from dietary.

Inspectors wroteBased on review of menus, policy review, observations and interviews, the facility failed to ensure that menus were followed for all four days of the survey. The deficient practice has the potential to affect all 69 residents that receive food from dietary.

Inspectors wroteBased on observations, document review, policy review and interview, the facility failed to ensure food was stored, prepared, and distributed in accordance with professional standards of practice including dishwasher sanitizing, cleaning, food storage and handling and processing food for serving. The deficient practice has the potential to affect all 69 residents receiving food from dietary.

Inspectors wroteBased on observations, review of policy and interview, the facility failed to ensure the area around the garbage dumpster area was free of trash on four of four days of the survey. The deficient practice has the potential to affect all 69 residents.

Inspectors wroteBased on observations and interview, the facility failed to ensure that it maintained essential equipment in working condition. Specifically, the large walk-in refrigerator has been inoperable for over three months. The deficient practice has the potential to affect all 69 residents that receive food from dietary.

Inspectors wroteBased on interview and record review, the facility failed to ensure third party liability (TPL) forms were completed within 30 days for the final accounting for residents who expired. This affected three residents who expired and had money in their accounts (Residents #104, #107 and #106). In addition, the facility failed to provide notification when the resident's trust account reached $200 less than the Supplemental Security Income (SSI) resource for four residents (Resident #7, #101, #102, #105). The facility held funds for 51 residents. The census was 74. Review of the facility Resident's Rights Policy, undated, showed the following: -Notice of certain balances: The facility must notify each resident that received Medicaid benefits: -When the amount in the resident's account reaches $200 less than the SSI resource limit for one person; [...]

Inspectors wroteBased on observations and interview, the facility failed to maintain a clean, comfortable, and homelike environment for one of two floors, (the secured second floor) affecting the 30 residents of the second floor. Specifically, the facility failed to maintain an environment free of food splatters on the walls, missing ceiling tiles, functioning door handles, holes in bedroom walls, holes in bathroom walls, unclean surfaces of tables, bathroom tiles, and clean equipment for the ice container creating an unpleasant environment for the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure newly hired employees were screened to rule out the presence of a Federal Indicator, with the Certified Nurse Aide (CNA) Registry for seven staff members. A sample of 10 employees hired were reviewed. The facility hired at least 100 new employees since the last survey. The census was 74. Review of the facility's Abuse Prevention Program, dated 9/29/22, showed the following: -Procedures for Prevention -Pre-employment Screening of Potential Employees: This facility will not knowingly employ any individual convicted of resident abuse, neglect, or misappropriation of property. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that diets provided were prepared and distributed as prescribed by the residents' physician for seven residents (R12, R43, R35, R171, R50, R4 and R26 ) out of 26 residents in the sample. The deficient practice has the potential for residents to lose weight.

Inspectors wroteBased on interview and record review, the facility failed to follow their tuberculosis (TB, a potentially serious infectious bacterial disease that mainly affects the lungs) policy when staff failed to complete a two step and the annual one step of the employee TB screening tests in a timely manner for a total of five employees. The census was 74. Review of the facility's Tuberculosis Policy, dated 2005, showed the following; -Tuberculosis (TB) Screening - Employees -It is the policy of this facility that all healthcare workers will undergo testing for tuberculosis upon hire. Initial testing will be completed using the two-step tuberculin skin test (TST) procedure. The first dose being administered within seven days after being employed and the second dose administered one to three weeks after the first test, if the first test is negative. 1. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to treat four of 26 sample residents (R) 14, R27, R171, and R220) with dignity and respect by failing to assist R171 with clean socks, to assist R220 to obtain clothing to wear instead of the hospital gown, and staff standing while assisting two (R27 and R14) residents to eat their meal. These failures created an undignified manor of care for the four residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide an alternative communication device for one resident (Resident (R) 35) of 26 sampled residents which failed to allow R35, who is non-verbal, a means to express himself.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide needed care in accordance with the resident's preferences for one of one resident (Resident (R)220) in the sample of 26 resident reviewed for skin care This failure had the potential to affect the physical, mental, and psychosocial health and well-being of the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent. A total of three errors occurred out of 30 opportunities for error due to residents not receiving their medications on time for one resident (Residents (R)11) of six residents observed for medication administration. In addition, one of six residents (R41) received a medication that did not have a physician's order. The facility medication error rate was 6.67%. This failure had the potential to affect the accurate dosing of medication administered to the residents.

Inspectors wroteBased on observations, and interviews, the facility failed to ensure that the food residents received was at an appetizing temperature for one of three meals on one of four survey days. The deficient practice has the potential to affect all 69 residents who receive food from dietary.

Inspectors wroteBased on observations and interviews, the facility failed to post the required daily nurse staffing report at any place in the nursing facility. This deficient practice had the potential to affect all residents and visitors of the facility.

Inspectors wroteSee the deficiency cited at Event K4Wl12. Based on observation, interview and record review, the facility failed to ensure one resident (Resident #1) was free from significant medication error by not obtaining the resident's prescribed narcotic in a timely manner. The sample size was three. The census 67. Review of the facility's Medication Order Policy, undated, showed: -This facility shall use uniform guidelines for the ordering of medication; -Medications should be administered only upon the signed order of a person lawfully authorized to prescribe; -Each medication order should be documented with the date, time and signature of the person receiving the order; -The order should be recorded on the physician order sheet, and the medication administration record (MAR); -Transcribe newly prescribed medication on the MAR or treatment record. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe, comfortable, homelike environment by failing address plumbing and roofing issues that led to bulging, brown and rust-colored ceiling tiles in three residents' rooms (Resident #10, Resident #11, and Resident #12) and in the 100 hall shower room, that one resident used daily (Resident #1). The facility also failed to complete timely repairs and improvements to the walls in the main entrance lobby hallway leading to the main elevator. The sample size was 12. The census was 66. Review of the facility's Routine Maintenance policy, revision date, 8/16/22, showed maintenance staff is responsible to ensure that preventative, routine, maintenance is completed in compliance with applicable life safety standards and needs of the facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident #1) was free from significant medication error by not obtaining the resident's prescribed narcotic in a timely manner. The sample size was three. The census 67. Review of the facility's Medication Order Policy, undated, showed: -This facility shall use uniform guidelines for the ordering of medication; -Medications should be administered only upon the signed order of a person lawfully authorized to prescribe; -Each medication order should be documented with the date, time and signature of the person receiving the order; -The order should be recorded on the physician order sheet, and the medication administration record (MAR); -Transcribe newly prescribed medication on the MAR or treatment record. [...]

Inspectors wroteBased on interview and record review, the facility failed to designate a person to serve as the director of food and nutrition services with the appropriate certification, when a consultant Registered Dietician (RD) was not employed full-time with the facility. The census was 74. Review of the facility assessment, dated 5/22/23, showed the staffing plan included one contracted RD and one director of food/nutrition services. During an interview on 8/10/23 at 1:18 P.M., the Culinary Services Director said he worked as a cook in the facility for two years and has been employed in his current position for five months. He has a food certification. He was unable to specify the area of certification or provide a copy of the certification. The facility has a RD consultant with corporate who does not work with the facility full-time. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The facility failed to have a system for monitoring proper functioning of the dish machine to ensure proper sanitation. The facility failed to ensure foods were stored at the appropriate temperatures to prevent foodborne illness. The facility failed to ensure foods were prepared and distributed under sanitary conditions when dietary staff failed to exhibit appropriate hand hygiene while serving food and to have facial hair properly covered during food preparation. The facility failed to appropriately store and handle dishware, and to store bulk dry goods and canned goods in a manner to protect from cross contamination. [...]

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 August 2022 through October 2022. In addition, the facility failed to ensure residents who held funds below $50.00 in the interest bearing bank account were credited interest earned on the account. (Residents #62, #16, #426, #28, #41, #276, #52, #427, #428, #9, #2, #26, #50, #429, #430 and #27). The census was 74. Review of the facility's Resident Trust Fund (RTF) policy, revised 2/2020, showed: -The Business Office Manager has the primary responsibility for ensuring that residents' funds are appropriate and legitimate; -Interest is to be posted once a month to resident accounts with an account balance of $50.00 or greater. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure general accounting principles were followed for an accurate accounting of all monies, by failing to research outstanding checks. This affected residents whose funds were managed by the facility. The census was 74. 1. Review of the facility provided September 2022 Check Listing Report dated 9/30/22, showed the following outstanding checks that had not cleared the bank as of 8/8/23. Check Number Date Amount 1043 08/17/2020 $3,250.11 1137 01/27/2021 $0.65 1311 08/04/2021 $3,483.10 1318 08/10/2021 $12.00 1389 11/08/2021 $136.00 1420 12/14/2021 $0.80 Review of the facility October 2022 Bank Reconciliation on 8/9/23, showed the checks written in 2020 and 2021 were not listed under the reconciled checks. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had the right to reasonable access to the use of a telephone in a place where calls could be made without being overheard. The facility additionally failed to provide reasonable access to send and receive mail on the weekends. The facility census was 74. Review of the Resident's Handbook, undated, showed: A telephone for private calls is available for resident use 24 hours a day and each resident room is equipped for a telephone. Review of the Resident's admission Packet, undated, showed: A resident has the right to have a reasonable access to the private use of a phone. 1. Observation and interview on 8/8/23 at 7:25 A.M., showed, on the second floor, two white telephones in an unlocked room on a desk. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure they provided residents a homelike environment by failing to maintain clean shower rooms on the 200 and 100 halls, out of three shower rooms observed. The resident sample was 18. The census was 74. 1. Review of the facility's House Keeping Duties list, showed the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized care plans, to address the specific needs of the residents for four of 18 sampled residents (Residents #4, #61,#70, and #277). The census was 74. 1. Review of Resident #4's Medical Record, showed: -Medical diagnoses included: Pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) to the left hip, abnormal weight loss, muscle weakness, depression, heart failure, and cerebral infarction (a blood clot in the brain affecting cognition); -The following care areas were noted on the quarterly Minimum Data Set, (MDS) a federally mandated assessment instrument completed by facility staff, dated 7/17/23: Cognitive loss, urinary incontinence, psychosocial wellbeing, and falls; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who required assistance with activities of daily living (ADLs) received personal care and showers in accordance with their needs and preferences (Residents #61, #40, #21 and #70). The sample was 18. The census was 74. Review of the facility's Bathing a Resident policy, revised July 2014, showed: -Policy: It is the policy of the company that residents will receive a shower/bath will be scheduled regularly and as needed (PRN); -Procedures included: -Check with the nurse to determine if special precautions need to be taken while showering or bathing the resident, e.g., cast, dressing, isolation precautions, toenails can be trimmed; -Assist the resident in showering/bathing if necessary; -Wash from head to feet, shampoo hair (if necessary), then wash perineal area; -Apply deodorant and lotion. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement an ongoing resident centered activity program that incorporates the residents' interests and maintains and/or improves residents' physical, mental and psychosocial well-being for three residents (Resident #61, Resident #5 and Resident #63). The sample was 18. The census was 74. Review of the facility's undated Activity Program policy, showed: -An ongoing program of activities is designed to meet the needs of each resident; -The activity program is designed to encourage restoration to self-care and maintenance of normal activity which is geared to the individual resident's needs; -Activities are scheduled daily and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup and critique of the program; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the activities program was directed by a qualified professional. The census was 74. Review of the facility's undated Activities Program Staffing policy, showed: -The activity program is staffed with personnel who have appropriate training and experience to meet the needs and interests of each resident; -The activity program is under the direct supervision of a qualified professional who: - Is a qualified therapeutic specialist or an activities professional who is licensed or registered, if applicable, by the state in which the person is practicing; -Is eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body on or after October 1, 1990; -Or has two years' experience in a social or recreational program within the last five years; [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an ongoing restorative nursing program (RNP) to ensure residents maintained their functional ability to the greatest extent possible (Residents #40, #16, #31, #35 and #57). The facility identified 20 residents as qualified for restorative therapy (RT) services. The census was 74. Review of the facility's Restorative Nursing policy, revised July 2014, showed: -Policy: It is the policy of the company to provide restorative nursing which promotes the resident's ability to live as independently and safely as possible. Restorative nursing focuses on achieving and maintaining the optimum level of physical, mental, and psychological function of the resident; -Procedure included: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper gait belt usage and the care planning of gait belt usage to ensure resident safety for two of 18 sampled residents (Residents #57 and #35) and failed to complete a smoking assessment and supervision for one sampled resident (Resident #126). The census was 74. 1. Review of the facility's Gait Belt Use policy, revised July 2014, showed the following: -Policy: It is the policy that gait belts will be used when staff are transferring weight bearing residents or assisting them with walking for the safety of the resident or the employee; -Procedure: -Explain to the resident what is about to happen. The gait belt is placed around the resident's waist; -Fasten the gait belt snuggly, but not too tight. Be careful of tubes, wounds, or incisions; [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the Director of Nursing (DON) did not serve as charge nurse when the facility's average daily census was greater than 60 residents. The facility census was 74. Review of the facility's resident census for the duration of the survey and licensure process, showed a daily census of 72 residents at the facility. Observation of the lunch meal on 8/9/23 at 5:41 P.M. showed a resident rested in bed with the dinner meal placed on his/her side table over the bed. The facility DON provided assistance to the resident with eating the meal of navy bean soup, a fruit cup, and a tuna sandwich. During interview on 8/11/23 at 9:03 A.M., the facility administrator and DON estimated the average daily census at the facility is around 70 residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored per acceptable standards of practice. These practices affected one out of three medication carts and one out of one medication room reviewed. The census was 74. 1. Review of the facility's Medication Labels policy, undated, showed: -Labels are permanently affixed to the outside of the prescription container; -Each prescription medication label or package includes: -The resident's name; -Specific directions for use, including route of administration; -Medication name; -Strength of medication; -Prescribers name; -Date dispensed; -Quantity of medication; -Beyond use (or expiration) date of medication on the package. Review of the facility's Controlled Substance policy, revised July/2014, showed: [...]

Inspectors wroteBased on observation, interview and record review, staff failed to maintain resident dignity by speaking to and assisting one resident (Resident # 37) during mealtime in a disrespectful manner. Additionally, the facility failed to ensure one resident came to the dining room in clean and odor free clothing (Resident #61) and one resident wore proper undergarments to enhance his/her dignity (Resident #70). The census was 74. Review of the Resident Rights admission Packet, undated, showed: The facility shall care for its residents in a manner and in an environment that promotes maintenance or enhancement of each resident's quality of life. 1. Review of Resident #37's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/17/23, showed: -The resident is rarely or never understood; -No rejection of care or behaviors; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide reasonable accommodations of individual needs and preferences by failing to ensure Resident #57 had assistive devices while eating. The sample was 18. The census was 74. Review of Resident #57's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/7/23, showed the following: -Diagnoses of legal blindness, chronic kidney disease and hypertension; Cognition not listed; -Supervision/touch assistance needed when eating. Review of the resident's care plan, dated 2/7/23, showed the following: -Problem: resident is on a mechanical soft diet. He/She has special devices needed during meals: divided plate, dycem (a non slip material used under a resident's plate to avoid plate movement), and food in bowls; -Goal: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assure that each resident receives an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas and are knowledgeable about the resident's status, needs, strengths, and areas of decline. Inaccurate assessments occurred for two of three closed record sampled residents (Residents #73 and #74). The census was 74. 1. Review of Resident #73's discharge Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) assessment, dated [DATE], showed: -The resident discharged [DATE]; -discharged to an acute care hospital. Review of the resident's electronic physician order sheet (ePOS), showed an order dated [DATE], for discharge to a different long term care facility with current medications. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care provided met acceptable standards of nursing practice. This included medication administration incongruent with the medical record for one resident and nutritional tube feedings not provided as ordered for one resident (Residents #1 and #55). The facility census was 74. Review of the facility's Monitoring of Medication Administration policy, undated, showed: -To administer all medication safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms, and help in diagnosis; -Read and follow any special instructions written on labels. 1. Review of Resident #1's electronic physician order sheet (ePOS), showed: -An order dated 11/20/17, for Melatonin (natural sleep supplement) 3 milligram (mg). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide diets and supplements as ordered to ensure residents maintained acceptable nutritional status for two residents with weight loss, one of which was significant (Residents #4 and #40). The facility also failed to appropriately monitor meal intake and develop and/or implement resident specific-interventions to address weight loss. The sample was 18. The census was 74. Review of the facility's Nutritional Assessments policy, revised January 2012, showed: -Policy: All residents who experience significant or undesirable weight loss shall be assessed for nutritional status and required intervention by the Registered, Licensed Dietitian (RDLD). A course of action increasing calories shall be implemented unless the weight loss is deemed desirable and necessary for medical status. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to establish a system of records of receipt for all controlled drugs in sufficient detail to enable an accurate reconciliation for one out of one medication room reviewed. The census was 74. Review of the facility's Controlled Substance policy, revised July 2014, showed: -Controlled substance must be counted upon delivery. The nurse receiving the order, along with the person delivering the medication order, must count the controlled substances together; both individuals must sign the designated narcotic record; -Controlled substances must be stored in the mediation room in a locked container or in a mediation cart in a locked box, separate from containers for any non-controlled medications. [...]

Inspectors wroteBased interview and record review, the facility failed to ensure as needed (PRN) psychotropic medications were re-evaluated after 14 days for two residents (Resident #50 and Resident #61). The sample size was 18. The census was 74. Review of the facility's Psychotropic Medication Use policy, revised December 2018, showed: -Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record and PRN orders for psychotropic drugs are limited to 14 days. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to administer medications with a less than five percent medication error rate. Out of 25 opportunities for error, two errors occurred, resulting in an 8% medication error rate (Resident #1). The sample size was 25. The census was 74. Review of the facility's undated Monitoring of Medication Administration policy, showed: -Based on the facility medication administration policy designated nursing staff to administer all medication safely and appropriately to aid resident to overcome illness, relieve and prevent symptoms, and help in diagnosis; -Review the resident's Medication Administration Record (MAR). Read each order entirely; -If there is any discrepancy between the MAR and the label, check physician orders before administering medication; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and follow recipes to ensure adequate nutritive value of fortified foods (super cereal and power potatoes) used to assist residents in maintaining acceptable nutritional status (Residents #40 and #4). The census was 74. 1. Review of Resident #40's medical record, showed diagnoses included high blood pressure, high cholesterol, low potassium, anemia (blood disorder), multiple sclerosis (nervous system disease affecting the brain and spinal cord), anxiety, and depression. Review of the resident's electronic Physician Order Sheet (ePOS), showed an order, dated 10/19/22, for regular diet. Special instructions included super cereal for breakfast and power potatoes for lunch. Review of the resident's nurse practitioner note, dated 6/14/23, showed chief complaint of follow-up related to weight loss. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure arrangements were made for pain management services outside of the facility for two residents prescribed narcotic pain medication (Residents #16 and #126). The sample was 18. The census was 74. 1. Review of Resident #16's medical record, showed diagnoses included pain in left knee and anxiety. Review of the resident's electronic Physician Order Sheet (ePOS), showed an order, dated 5/12/23, for tramadol (pain medication) 50 milligrams (mg), three times a day as needed (PRN). Review of the resident's June 2023 electronic Medication Administration Record (eMAR), showed; -Tramadol administered 46 times; -No tramadol documented as administered after 6/24/23. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/28/23, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medical records were accurately documented in accordance with acceptable professional standards of practice when staff failed to document skin assessments for one resident with a blister on his/her left heel (Resident #5). Staff documented nutritional supplements as administered for two residents (Residents #40 and #4) when the supplements were not provided, and staff failed to accurately document meal intake in accordance with physician orders. The sample was 18. The census was 74. Review of the facility's Charting policy, revised February 2012, showed: -Policy: It is the policy of the company that all services provided to the residents, or any changes in the resident's condition, shall be recorded in the resident's medical record; -Procedures included: [...]

Inspectors wroteBased on observation and interview, the facility failed to post, in a form and manner accessible and understandable to residents and resident representatives, the name, address, and telephone number for the State Survey Agency, and a statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation, including but not limited to resident abuse, neglect, exploitation, and misappropriation of resident property. The census was 74. Observations throughout the survey from 8/7/23 through 8/11/23, showed no contact information for the State Survey Agency posted on the 1st or 2nd floors, where resident rooms and common areas were located. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident #307) was free of significant medication errors when they failed to obtain and administer two psychotropic medications as ordered by the physician for approximately one month. The facility census was 99. 1. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 2/4/20, showed staff assessed the resident as follows: -Cognitively intact; -Had delusions; -Rejected care; -Independent with bed mobility, transfers, walking, dressing, eating, toilet use and personal hygiene; -Continent of bowel and bladder; -Diagnosed with bipolar disorder, anxiety and depression. Review of hospital discharge papers showed the following: -The resident was admitted for inpatient psychiatric treatment on 1/13/20 and discharged on 2/4/20; [...]

Inspectors wroteBased on interview and record review, facility staff failed to complete a baseline care plan within 48 hours of admission and failed to document the baseline care plan was reviewed with the resident or responsible party for two residents (Residents #77, #241) out of 24 sampled residents. The facility census was 99. The administrator said the facility does not have a policy directing staff on completion of the baseline care plan. 1. Review of Resident #77's Minimum Data Set (MDS), a federally mandated assessment tool, dated 1/3/20, showed staff assessed the resident as follows: -admission date of 1/3/20; -Moderate cognitive impairment; -Total physical dependence of one staff for transfers, dressing, toileting, personal hygiene, and bathing; -Extensive physical assistance of one staff for locomotion; -Limited physical assistance of one staff for eating; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to ensure they observed three residents (Residents #19, #28 and #44) take their medications, failed to ensure two residents (Residents #28 and #47) did not have inhalers left at their bedsides, and failed to apply the appropriate treatment to one resident's (Resident #53) pressure ulcer. The facility census was 99. 1. Observation on 3/3/20 at 4:48 P.M., showed Certified Medication Technician (CMT) K administered to Resident #28, the following medications: -Docusate sodium (laxative) 100 milligrams (mg); -Eliquis (anticoagulant) 100 mg tablet; -Tamsulosin (treats symptoms of enlarged prostate) 0.4 mg capsule. The CMT handed the resident a cup of the three medications, then left the resident's room and did not observe the resident take the medications. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Director of Nursing (DON) served as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents. The facility census was 99. 1. Review of the Facility Assessment, dated June 2019, showed it did not address the DON serving as a charge nurse. Review of the facility's Daily Assignments schedule, dated 3/1/20 - 3/6/20, showed the DON was assigned to work as a charge nurse on the day shift on Monday, 3/2/20, and on on Tuesday 3/3/20. During an interview, the DON said he/she had been employed at the facility for two weeks. The DON said, in addition to occasionally working as the charge nurse for a shift, the DON covers the floor when a nurse must leave early in the morning or come in late in the evening. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the call light bulbs illuminated in the hallway for resident rooms and resident bathrooms when the call light button was activated. This practice potentially affected all residents in the facility. The facility census was 99 residents. 1. Observations with the Maintenance supervisor on 3/06/20, showed: -At 8:56 A.M., room [ROOM NUMBER], the call light to the hallway was burnt out. -At 10:29 AM., the call light bulb on the ground level and used by residents when in activities had been disabled and was not in working condition. During an interview on 3/06/20 at 10:29 A.M., the maintenance director said he did not know about these, because he had not been told by the staff there was a problem.

Inspectors wroteBased on observation, interview and record review, facility staff failed to ensure two dependent residents (Residents #53 and #72) had their call lights within reach to allow them to call when they required staff assistance. The facility census was 99. 1. Review of Resident #72's most recent Minimum Data Set (MDS), a federally mandated assessment tool, dated 1/14/20, showed the following staff assessment: -Understands others; -Usually understood; -Dependence on staff assistance for completion of his/her activities of daily living (ADLs). Review of the resident's comprehensive care plan for the area of ADL functional status, not dated, showed the resident needs assistance from one staff member. Review of the resident's care card showed the following: -Staff are directed to assist x 1 with all ADLs; -The resident self-propels in a wheelchair; -The resident is at risk for falls; [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure one resident's (Resident #77) physician's orders for his/her code status matched the resident's advance directive wishes and failed to ensure two residents' (Residents #65 and #307) current physician's orders listed the resident's code status. The facility census was 99. 1. Review of Resident #65's code status form in front of the medical record, dated [DATE], showed the resident wished to be a full code. Review of the resident's physician's order sheet (POS) dated [DATE]-[DATE] showed no code status listed on the resident's current physician's orders. 2. Review of Resident #77's Code Status Form in his/her medical record showed it is his/her choice to be a Full Code (Cardio Pulmonary Resuscitation (CPR) would be performed if the resident's heart and/or breathing stopped). [...]

Inspectors wroteBased on interview and record review, facility staff failed to revise, review and/or update the comprehensive care plan for three residents (Residents #31, #44, and #46). Review of the facility's undated Comprehensive Care Plan Development policy and procedure, showed it is the policy of the facility to complete a comprehensive care plan for each resident requiring a Minimum Data Set (MDS) assessment and care area assessment (CAA) completion. 1) The care plan is based on the CAA process, which is required for Omnibus Budget Reconciliation Act (OBRA)-required comprehensive assessments. 2) After completing the MDS and CAA portions of the comprehensive assessment, the interdisciplinary team must evaluate the information gained to develop a care plan that addresses those findings in the context of the resident's strengths, problems, and needs. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to provide adequate and appropriate perineal cleansing for two dependent residents (Residents #23 and #46) and failed to ensure good grooming for one resident's (Resident #72) fingernails. The facility census was 99. 1. Review of Resident #23's most recent MDS, dated [DATE], showed the following staff assessment: - Required extensive assistance from staff for dressing, toileting and personal hygiene; - Always incontinent of bladder; - Frequently incontinent of bowel; - Diagnosed with a urinary tract infection (UTI). Review of the resident's care plan, with multiple dates, showed the following: - The resident was at risk for pressure ulcers. Staff were directed to manage moisture (skin and incontinence management); - The resident was reluctant to perform personal hygiene without assistance. [...]

Inspectors wroteBased on observation and record review, facility staff failed to implement new interventions for one resident (Resident #66) after he/she resident had multiple falls. In addition, staff failed to follow the facility policy for falls. The facility census was 99. Review of the facility's Tracking Record for Improving Patient Safety (TRIPS), undated, showed the following: - It is the policy of this facility that a TRIPS form is completed on every resident experiencing a fall; - After evaluating and treating the resident immediately, the nurse should investigate the circumstances of the falls and look at all possible causes. All licensed nurses will be trained in the immediate fall response; - The Falls Nurse Coordinator will use the data recorded on the TRIPS form to identify trends related to types of falls. Such details include location, time and activity; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for one resident (Resident #241), when they did not evaluate the resident's usual patterns of behavior, did not document changes in the resident's behavior, did not document they informed the physician about changes in a resident's behavior, and did not implement individualized non-pharmacological interventions to address the resident's behavioral symptoms. The facility census was 99. Review of the facility's Behavior Management Policy, undated, showed the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to ensure one resident (Resident #16) was not given psychotropic medication unless necessary, when they started the resident on Seroquel (an antipsychotic), after the hospital directed this medication be discontinued, increased the dose of this medication from 12.5 mg to 50 mg without any indications to do so, and did not address a pharmacist's recommendation to clarify the dose of the Seroquel. Additionally, the facility staff failed to perform Gradual Dose Reductions (GDRs) on psychotropic medications in accordance with Centers for Medicare & Medicaid Services (CMS) guidelines for one resident (Resident #78). The facility census was 99. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to ensure they administered medications with an error rate of less than five percent. Facility staff made two errors of a total of 32 medications passed, yielding an error rate of 6.25%. The facility census was 99. 1. Review of Resident #18's physician's order sheet (POS) dated 3/1/20-3/31/20, showed a physician's order for Meloxicam (a non-steroidal anti-inflammatory medication used to treat arthritis) tablet, give one by mouth twice daily with food. Review of potential side effects of Meloxicam include upset stomach, nausea, vomiting, heartburn, diarrhea constipation, and serious gastrointestinal effects including bleeding, ulceration and perforation of the stomach or intestines. [...]

Inspectors wroteBased on observation and interview, facility staff failed to label and store medications in an appropriate manner when they failed to date insulin and multi-use vials on the date the vials were opened, failed to ensure medication carts were free of loose pills, and failed to discard expired medications. The facility census was 99. 1. Observation on 3/5/20 at 10:17 A.M., of the medication room on the first floor of the facility showed the following: In an upper storage cabinet: -A 100 count box of bisacodyl suppositories (laxative) with an expiration date of 9/19; -A four ounce bottle of Ultra tuss cough suppressant expectorant with an expiration date of 9/19; -A 100 count box of mucus relief guaifenesin (reduces chest congestion) 400 mg, with an expiration date of 12/19; -A one-half ounce bottle of ear drops earwax removal aide with an expiration date of 10/19; [...]

Inspectors wroteBased on observation and interview, facility staff failed to adequately clean and disinfect multi-use blood glucose meters between resident use and failed to clean vials of insulin prior to removing insulin for injection for one resident (Resident #19). The facility census was 99. 1. Observation on 3/3/20 at 4:57 P.M., showed Certified Medication Technician (CMT) K obtained the multi-use blood glucose meter from a container in the top drawer of the CMT medication cart. The CMT did not clean the machine before he/she used the machine to check Resident #19's fingerstick blood glucose level. After obtaining the blood glucose result, the CMT placed the blood glucose meter back into the top drawer of the medication cart without cleaning the meter. [...]

Inspectors wroteBased on interview and record review, facility staff failed to maintain and follow policies and procedures for immunization of residents against pneumococcal disease as required. The facility staff failed to provide and document provision of pertinent information regarding the pneumococcal vaccine including the benefits and potential side effects of the pneumococcal vaccine for six residents (Residents #1, #6, #8, #21, #77, and #88). The facility also failed to assess and vaccinate eligible residents with the pneumococcal vaccine with recommended doses of pneumococcal vaccine as indicated by the Centers for Disease Control (CDC) guidelines. The facility census was 99. Review of the US Department of Health and Human Services CDC Pneumococcal Vaccine Timing for Adults dated 11/30/15 showed the following: -Two pneumococcal vaccines were recommended for adults: [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to post the required daily nurse staffing hours in a prominent place readily accessible to residents. The facility census was 99. 1. Observation on 3/2/20 at 11:30 A.M., showed the nurse staffing hours posted on a bulletin board on the ground level of the facility across from the timeclock. The staffing hours were posted at eye level when standing and could not be easily viewed from a sitting position, such as a from a wheelchair. Observation on 3/3, 3/4, 3/5, and 3/620, showed the 24 hour nurse staffing to be posted on a bulletin board on the ground level. Observation showed the 24 hour nurse staffing was not available to all residents on the Floor 1 and Floor 2. [...]