Delhaven Manor

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain physician orders for monitoring and care of a gastrostomy tube (g-tube, a medical device placed through the belly directly into the stomach to deliver food, liquids, and medication) for one resident (Resident #3). The sample was 5. The census was 58. Review of the facility's Enteral Nutrition policy, dated November 2018, showed the following:-Policy Statement: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents requiring dialysis received services consistent with professional standards of practice when staff failed to conduct an ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments for two residents (Residents #1 and #3). The facility identified two residents receiving dialysis and problems were found with both. The sample was 3. The census was 35. 1. Review of Resident #1's medical record, showed:-admission date 2/5/26;-Diagnoses included end stage renal disease (ESRD, permanent kidney failure that requires a regular course of dialysis or a kidney transplant). Review of the resident nurse's note, dated 2/5/2026 at 1:42 P.M., showed the resident arrived via transportation from the dialysis center. [...]

Inspectors wroteBased on observation and interview, the facility failed to label, date, and cover food in the kitchen. In addition, the facility failed to ensure that kitchen equipment was clean and was in proper working order. These deficient practices had the potential to affect all residents who consumed food from the facility kitchen. The census was 60. 1. Observations of the kitchen dry storage room, showed: -On 11/6/24 at 11:14 A.M., 11/7/24 at 4:14 P.M., and 11/8/24 at 2:46 P.M.,: -A package of opened mostaccioli noodles wrapped in plastic without a date; -A package of opened cheese flakes wrapped in plastic without a date; -On 11/6/24 at 11:14 A.M. and 11/7/24 at 4:14 P.M., a package of opened stuffing mix wrapped in plastic without a date. 2. Observation on 11/6/24 at 11:14 A.M. and 11/7/24 at 4:14 P.M., showed: -Walk in cooler: -Tortilla shells opened, wrapped in plastic, and without a date; [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain a surety bond sufficient to ensure the protection of resident funds. This deficiency had the potential to affect all residents who have money in the resident trust fund. The census was 60. Review of the facility's Surety Bond Invoice, dated 12/28/23, showed a bond amount of $75000. Review of the facility's average resident trust fund balance for the previous twelve months, showed: -A monthly average of $52,000.00; -For this amount, the bond amount should have been $78,000. During an interview on 11/12/24 at 2:00 P.M., the Business Office Manager said she was not aware the amount was not sufficient and would request an increase immediately. The bond amount should have been sufficient. During an interview on 11/13/24 at 2:40 P.M., the Administrator said he was unaware the bond amount was not sufficient. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to place signage and follow indications for enhanced barrier precautions (EBP, an infection control intervention that utilizes personal protective equipment (PPE) to reduce the spread of multidrug-resistant organisms (MDROs)) for two residents who had pressure ulcers (open wounds that occur when skin and tissue are damaged by prolonged pressure), and an indwelling urinary catheter (a flexible tube that drains urine from the bladder into a collection bag) (Residents #42 and #38). In addition, the facility failed to ensure the indwelling urinary catheter bag was off the floor for one resident (Resident #38). Furthermore, the facility failed to ensure the nebulizer mask was stored in bag or clean container when not in use for one resident (Resident #45). The sample was 18. The census was 60. [...]

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 of three sampled residents who expired and had money in their accounts longer than 30 days (Residents #314, #315 and #316). The census was 60. 1. Review of Resident #314's financial records, showed: -Expired on [DATE]; -Ending balance of $390.49; -TPL form sent on [DATE]. 2. Review of Resident #315's financial records, showed: -Expired on [DATE]; -Ending balance of $29.04; -TPL form sent on [DATE]. 3. Review of Resident #316's financial records, showed: -Expired on [DATE]; -Ending balance of $20.04; -TPL form sent on [DATE]. 4. During an interview on [DATE] at 3:42 P.M., the Business Office Manager (BOM) said the facility was supposed to send the TPL form within 30 days. [...]

Inspectors wroteBased on interview and record review, the facility failed to assure the residents' Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) accurately reflect the residents' status for two of 26 sampled residents (Resident #57 and #60). The census was 60. 1. Review of Resident #57's significant change MDS, dated [DATE], showed: -admitted to the facility: [DATE]; -Diagnoses included high blood pressure, aphasia (language disorder that affects a person's ability to understand, speak, read and write), and depression; -Special services received while a resident: Hospice Care; -Does the resident have a condition or chronic disease that may result in life expectancy less than six months: No; -Staff failed to accurately document the resident's condition resulted in a life expectancy of less than six months necessitating hospice services. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who received dialysis (the clinical purification of blood as a substitute for the normal function of the kidney) had documented assessments and monitoring related to dialysis and ongoing documented communication with the dialysis center. The facility identified two residents who received dialysis, and one resident was sampled (Resident #53). In addition, the facility failed to have a copy of the dialysis contract. The sample was 18. The census was 60. Review of the facility's Care of a Resident with End-Stage Renal Disease Policy, dated reviewed 10/12/24, showed: -Policy statement: residents with end stage renal disease (ESRD, chronic irreversible kidney failure) will be cared for according to currently recognized standards of care; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 37 opportunities observed, three errors occurred resulting in an 8.11% error rate (Resident #50). The census was 60. Review of the facility's Medication Administration Policy, undated, showed: -Only licensed personnel or certified medical technicians (CMT) are assigned responsibility of preparing, administering, and recording medication or permitted access to drug storage areas; -Medication may be administered to a resident only if ordered by a practitioner licensed to prescribe medication in that location. Review of the facility's Administering Medications through a Metered Dose Inhaler Policy, dated reviewed 10/1/24, showed: -Purpose: The purpose of this procedure is to provide guidelines for the safe administration of inhaled medications; [...]

Inspectors wroteBased on observation and interview, the facility failed to provide accessible information on the location of the State Survey Agency hotline number that was readily available to residents in the facility without assistance. The census was 60. Observations throughout the survey on 11/ 7/24, 11/8/24 and 11/12/24 showed, the State Survey Agency number not posted in the facility. During a group interview on 11/8/24 at 9:55 A.M., seven residents, whom the facility identified as alert and oriented, attended the group meeting and said they did not know where the State Survey Agency hotline number was posted. During an interview on 11/12/24 at 3:17 P.M., the Director of Nursing said the State contact information was not posted. The facility has ordered a new poster and frame. [...]

Inspectors wroteSee the deficiency cited at F839 under event ID G60Z12. Based on observation, interview and record review, the facility failed to ensure staff transporting residents in the company vehicle held the proper driver license in accordance with Missouri state regulations, for one of one days of observation. This had the ability to affect all residents who were transported in the facility vehicles. The census was 61. Review of the Missouri State Driver's Guide, revised August 2023, showed the following: -A Class F license is Missouri's basic driver license and is needed to operate any motor vehicle other than one requiring the driver to have a Class A, B, C or E license. -Anyone who transports 14 or fewer passengers for pay or as part of his/her job must have a class E license; [...]

Inspectors wroteSee the deficiency cited at F850 under event ID G60Z12. Based on interview and record review, the facility failed to employ a qualified social worker on a full-time basis. The facility was licensed and certified for 156 residents. The current census was 61. Review of the facility's license and certification records, showed the facility licensed for 156 beds, of which 156 beds were certified for Medicaid and Medicare. Review of the facility's Social Worker's job description, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide necessary behavioral health care services for a resident's psychosocial well-being when staff did not address the resident's behaviors, which included alcohol use and verbal/physical aggression, for one resident (Resident #2). The facility failed to address the behaviors and inform staff how to handle the resident's escalating behaviors. The sample was eight. The census was 62. The Administrator was informed on [DATE] of an Immediate Jeopardy (IJ), which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor on-site verification. Review of the facility's Substance Use Disorder policy dated [DATE], showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff transporting residents in the company vehicle held the proper driver license in accordance with Missouri state regulations, for one of one days of observation. This had the ability to affect all residents who were transported in the facility vehicles. The census was 61. Review of the Missouri State Driver's Guide, revised August 2023, showed the following: -A Class F license is Missouri's basic driver license and is needed to operate any motor vehicle other than one requiring the driver to have a Class A, B, C or E license. -Anyone who transports 14 or fewer passengers for pay or as part of his/her job must have a class E license; [...]

Inspectors wroteBased on interview and record review, the facility failed to employ a qualified social worker on a full-time basis. The facility was licensed and certified for 156 residents. The current census was 61. Review of the facility's license and certification records, showed the facility licensed for 156 beds, of which 156 beds were certified for Medicaid and Medicare. Review of the facility's Social Worker's job description, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to establish a system of record for all controlled drugs with sufficient detail to enable an accurate reconciliation for four out of four narcotic count books reviewed. This had the potential to affect all residents with controlled substance orders. The census was 64. Review of the facility's Controlled Substances policy, revised November 2022, showed: -Dispensing and Reconciling Controlled Substances: -Controlled substance inventory if monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up; -Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident's right to be free from physical abuse was not violated (Resident #4) when a resident (Resident #5) hit the other resident in the face. The sample was 5. The census was 62. Review of the facility's Residents Rights policy, revised 2/2021, showed: -Be free from abuse, neglect, misappropriation of property, and exploitation; -Includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. Review of the facility's abuse and investigation and reporting policy, revised 7/2017, showed: -All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure services provided met professional standards of practice by not following the physician orders for two residents (Resident #1 and #4). The facility failed to administer all medication as ordered and did not document the reasons for the omissions. The sample was 5. The census was 62. Review of the facility's Medication orders policy revised November 2014, showed; Policy: The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. -Each resident must be under the care of a Licensed physician authorized to practice medicine in this state and must be seen by the physician at least every sixty (60) days; -A current list of orders must be maintained in the clinical record of each resident; -Orders must be written and maintained in chronological order. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure services provided met professional standards of practice by not following the physician orders for Resident #4. The facility failed to administer his/her medication and did not document the reasons and notification to the physician. The sample was 5. The census was 62. Review of the facility's Medication orders policy, revised November 2014, showed; -Policy: The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders; -Each resident must be under the care of a Licensed physician authorized to practice medicine in this state and must be seen by the physician at least every sixty (60) days; -A current list of orders must be maintained in the clinical record of each resident; -Orders must be written and maintained in chronological order. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide reasonable accommodation of needs and preferences for one resident when staff failed to assist him/her out of bed when he/she requested (Resident #1). The sample size was 3. The census was 60. Review of the facility's Activities of Daily Living (ADLs) Supporting policy, last reviewed by the facility 2/6/24, showed: -Policy Statement: Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living; -Policy Interpretation and Implementation: -Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive care plan to address the resident's specific needs, which included fall interventions. The staff failed to conduct fall investigations to determine fall causes and interventions for 3 of 3 falls. In addition, the faclity failed to revise the resident's care plan to address his/her change in mood and access to socialization (Resident #1). The sample size was 3. The census was 60. Review of the facility's Care Plans, Comprehensive Person-Centered, revised 3/2022, showed: -Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; -Policy Interpretation and Implementation: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to identify potential safety hazards for one resident's environment, who staff assessed as being unable to move while in bed, when the staff left the bed remote control under the resident's back (Resident #1). The resident's back applied pressure to the bed remote control and caused it to elevate to the highest position. This resulted in a one centimeter laceration of the head and a C-2 (a break in the second vertebra of the neck) neck fracture. In the two weeks following this fall with injury, the resident had two additional falls. The facility failed to investigate and implement additional safety interventions after each fall. The sample size was 7. The census was 60. Review of the facility's Falls-Clinical Protocol, revised 3/2018, showed: -Assessment and recognition: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to promote one of seven sampled resident's highest possible level of well-being, to assure the emotional and social needs of the resident were met/maintained. The facility also failed to address the resident's mental and psychosocial needs thoroughly, which negatively impacted him/her, causing feelings of isolation and sadness (Resident #1). The sample was 7. The census was 60. Review of the facility's Social Service Designee documentation policy, dated 2003, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to use the services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week. The staffing sheets were reviewed for the month of August, 2023 and no RN was scheduled for the weekend. The census was 60. Review of the facility's August 2023 staff schedule, reviewed on 8/25/23, showed: -No staff listed under the job description of RN supervisor; -Every shift identified the nurses working as Licensed Practical Nurses (LPNs); -No RNs scheduled; -Weekend dates with no RN coverage included 8/5, 8/6, 8/12, 8/13, 8/19, and 8/20/23. During an interview on 8/25/23 at 10:23 A.M., the Director of Nursing (DON) said she began employment at the facility in July 2023. He/She typically works Monday through Friday. The facility does not have an RN scheduled on the weekends. [...]

Inspectors wrote2. A review of Resident #110's Face Sheet revealed the facility admitted the resident on [DATE] with diagnoses that included chronic obstructive pulmonary disease, congestive heart failure, and diabetes mellitus. A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #110 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The MDS indicated Resident #110 was independent with bed mobility, transfers, and locomotion and required extensive assistance from staff with toilet use and personal hygiene. The MDS indicated Resident #110 was always continent of bladder and always incontinent of bowel. According to the MDS, Resident #110 had almost constant pain that the resident described as severe; the resident received a scheduled pain medication regimen. [...]

Inspectors wroteBased on resident and staff interviews and record reviews, it was determined the facility failed to provide quarterly financial statements to 2 (Resident #2 and Resident #24) of 24 residents who had resident trust accounts with the facility. The facility census was 57.

Inspectors wroteBased on interview, record review, and facility document and policy review, the facility failed to ensure Level 1 Preadmission Screening and Resident Reviews (PASARRs) were accurately completed upon admission for 2 (Resident #8 and Resident #54) of 3 residents reviewed for PASARR. Specifically, the facility failed to ensure Resident #8 had a Level I PASARR completed prior to admission and failed to ensure Resident #54's Level I PASARR was accurate and included mental illness diagnoses upon admission. The facility census was 57.

Inspectors wroteBased on observations, interviews, record review, and policy review, it was determined that the facility failed to provide services to residents who were unable to carry out activities of daily living (ADL) necessary to maintain good grooming and personal hygiene for 2 (Resident #23 and Resident #308) of 17 sampled residents reviewed for assistance with ADL care. Specifically, Resident #23 and Resident #308 had fingernails that were long with dirty substances underneath the nails. The facility census was 57.

Inspectors wroteBased on observations, interviews, and facility document and policy review, it was determined the facility failed to provide treatment to prevent further decrease in range of motion for 1 (Resident #23) of 2 residents reviewed for limited range of motion. The facility census was 57.

Inspectors wroteBased on interviews and record review, the facility failed to ensure ongoing communication and collaboration with the dialysis facility regarding dialysis care and services, and failed to ensure ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility were completed for 1 (Resident #44) of 2 residents reviewed for dialysis. The facility census was 57.

Inspectors wroteBased on record review, interview, and facility policy review, it was determined the facility failed to provide evidence of adequate monitoring for the effects of and/or responses to psychotropic medications for 1 (Resident #49) of 5 residents reviewed for unnecessary medications. The facility census was 57.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure 1 (Resident #44) of 3 residents who received insulin were free from significant medication errors. Specifically, the facility failed to ensure staff administered Resident #44's insulin as ordered by the physician. The facility census was 57.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident requests for less than $100.00 ($50.00 for Medicaid residents) were honored within the same day by not assuring residents had access to their trust account on the weekends. This deficient practice affected all the residents who had a resident trust account. The facility also failed to keep resident trust fund (RTF) accounts from being overdrawn for eight residents (Residents #214, #216, #217, #215, #212, #213, #30 and #52). The census was 59. 1. During the resident council group interview on 10/8/19 at 11:00 A.M., six out of six residents agreed the facility does not offer RTF banking hours on the weekends. Observation of the door to the facility business office, showed a sign posted stating, New bank hours: Monday through Friday 10 A.M. -12 P.M. and 2 P.M - 4 P.M. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure general accounting principles were followed, when they failed to provide documentation regarding quarterly resident trust fund statements. This affected all residents for whom the facility held funds. The census was 59. During the resident council group interview on 10/8/19 at 11:00 A.M., five out of six residents, whom the facility identified as cognitively intact, agreed the facility did not provide resident trust fund quarterly statements. No one knew their resident trust balance. During an interview on 10/9/19 at 12:38 P.M., the corporate bookkeeper and administrator said there was no documentation of quarterly statements being provided for the last quarter. Typically, they had residents sign the statements, but there was nothing on file to show statements were provided to the residents during the last quarter.

Inspectors wroteBased on interview and record review, the facility failed to maintain the bond amount for at least one and one-half times the average monthly balance of the residents' personal funds for the last twelve consecutive months from September 2018 to August 2019. The census was 59. Record review on 10/10/19 of the residents' personal funds account for the last twelve consecutive months from September 2018 to August 2019 showed the following: -The facility could not provide a reconciled bank statement for July 2019; - The facility's current approved bond amount equaled $35,000.00; - The average monthly balance for the residents' personal funds equaled $27,533.67; - An average monthly balance of $27,533.67 required a bond of at least $42,000.00. During an interview on 10/10/19 at 12:46 P.M., the corporate bookkeeper said the current bond amount was insufficient. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care plans reflected residents' current needs by not updating them to include a new pressure ulcer (pressure injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or friction), new/additional fall interventions and a resident's risk of pressure ulcers, including treatment and interventions, for three (Residents #5, #37 and #45) of 15 sampled residents. The census was 59. 1. Review of Resident #5's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/10/19, showed the following: -Moderate cognitive impairment; -Unable to ambulate; -Dependent on staff for all mobility and personal care; -Incontinent of bowel and bladder; -Risk of developing pressure ulcers: YES; -No skin breakdown; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff obtained diagnoses for antibiotics and psychotropic medications, clarify the dose of a heparin (blood thinner) flush, obtain code status (full code-all life preserving methods are performed, or no code-no life preserving methods are performed) orders, obtain the liter (L) flow for continuous oxygen administration, provide a diagnosis for the use of a supra-pubic catheter (SP cath-a small tube surgically inserted through the lower abdominal wall into the bladder to drain urine), follow up with the physician regarding a dietician's recommendations, and follow a physician's order for the use of heel protectors. This affected four residents (Residents #260, #259, #210 and #45). The sample size was 15. The census was 59. 1. Review of Resident #260's face sheet, showed the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their smoking policy by allowing two residents (Residents #12 and #38) to keep cigarettes and a lighter on their persons. The facility also failed to prevent resident access to razors by not removing razors from one resident's room (Resident #210) and allowing storage of razors in an unlocked cabinet drawer in the hall of the 3rd floor. The facility also failed to repair a call light in the 3rd floor shower room, which left exposed wires. The census was 59. Review of the facility's Smoking Policy, dated 9/21/17, showed the following: -All smokers will be supervised by staff to smoke; -All resident cigarettes are stored in container at the main reception desk on the first floor; -Cigarettes are given to the residents inside the smoke room only; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide thorough assessments, orders, monitoring and ongoing communication with the dialysis (the clinical purification of blood by dialysis as a substitute for the normal function of the kidney) center for three residents (Residents #49, #22 and #45). The facility identified four residents who received dialysis. Three of them were chosen for the sample of 15 and issues were found with all three of them. The census was 59. 1. Review of Resident #47's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/15/19, showed the following: -No cognitive impairment; -Total dependence on staff for most activities of daily living (ADLs); -Upper extremity impairment on one side; -Incontinent of bowel and bladder; -Received dialysis; -Diagnoses included diabetes and depression. [...]

Inspectors wroteBased on interview and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in a sufficient detail to enable an accurate reconciliation by not ensuring nursing staff signed at the beginning and end of each nursing shift, for two of four narcotic count books checked. The census was 59. 1. Review of the 300 Hall nurse's narcotic count sheet, dated October 2019, showed the following: -From 10/1 through 10/6/19, a total of 10 shifts without the on-coming nursing staff signature and/or initials for counting narcotics; -From 10/1 through 10/6/19, a total of 10 shifts without the off-going nursing staff signature and/or initials for counting narcotics. 2. Review of the 300 Hall Certified Medication Technician (CMT) narcotic count sheet, dated October 2019, showed the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow puree recipes to ensure food was prepared by methods that conserved nutritive value and flavor, for seven of seven residents who received pureed diets. The census was 59. 1. Observation on 10/8/19 at 10:05 A.M., showed [NAME] J stood at a kitchen counter and said he/she would puree seven servings of spaghetti and meatballs, and zucchini for the lunch meal. The blender bowl sat on the counter and contained pasta. [NAME] J said he/she put four tongs full of pasta in the bowl, which was about 8 ounces (oz). He/she added two, 6 oz. (12 oz. total) scoops of spaghetti sauce with an unknown number of meat balls. [NAME] J washed his/her hands, donned gloves and added 2 teaspoons of chicken base to two cups of hot water and stirred the mixture. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure food was dated when placed in the walk-in refrigerator. This deficient practice had the potential to affect all residents who ate at the facility. The census was 59. 1. Observation of the walk in refrigerator, showed the following: -On 10/7/19 at 10:31 A.M. and 5:30 P.M., and 10/8/19 at 10:05 A.M., two large pork tenderloins and four approximate 5 pound (lb) rolls of ground beef sat, undated, on a tray on the bottom shelf; -On 10/9/19 at 2:41 P.M., the pork tenderloins and four rolls of ground beef had a sticker, dated 10/9/19; -On 10/10/19 at 1:21 P.M., four rolls of ground beef, dated 10/9/19, remained on the tray on the bottom shelf and two pork tenderloins were gone. 2. Observation of the reach-in cooler, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to collaborate with hospice in the development of a coordinated plan of care for residents receiving hospice care. The facility also failed to maintain documentation of a continuation of services provided when one hospice provider went out of business, until the resident was admitted to another provider (Resident #15). The facility identified two residents who received hospice care. Both residents were included in the sample of 15, and problems were found with each of them (Residents #15 and #37). The census was 59. 1. Review of Resident #15's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/15/19, showed the following: -Severe cognitive impairment; -Unable to ambulate; -Required staff supervision for mobility and personal care; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident call light system remained functional for four of four shower rooms on the second floor and one shower room on the third floor. This affected all residents who showered in those shower rooms. The census was 59. 1. Observations on 10/7/19 at 11:39 A.M., 10/9/19 at 7:35 A.M., 10/10/19 at 7:35 A.M. and 1:26 P.M. and 10/11/19 at 7:00 A.M., of the third floor unlocked shower room across the hall from room [ROOM NUMBER], showed the call light detached from the wall and not in working order. 2. Observations on 10/11/19 of the second floor shower rooms, showed the following: -At 7:13 A.M., the shower room across from room [ROOM NUMBER] did not sound or light up outside the door when the string was pulled; [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to accurately code the Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, regarding life expectancy for one resident (Resident #15) and tracheostomy (trach, an opening in the neck to place a tube in the windpipe that allows air to enter the lungs) and the use of oxygen for one resident (Resident #46). The sample size was 15. The census was 59. 1. Review of Resident #15's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Unable to ambulate; -Supervision required for mobility and personal care; -Diagnoses included diabetes, dementia and chronic lung disease; -Life expectancy of less than six months: NO. Review of the medical record, showed he/she admitted to hospice on 2/21/18. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 26 opportunities, two errors occurred resulting in 7.69% medication error rate (Resident #38). The census was 59. Review of Resident #38's physician's order sheet (POS), dated 10/7/19 through 11/6/19, showed the following: -Diagnoses included high blood pressure and muscle spasms; -An order, dated 8/11/18, to administer Lisinopril (medication used to treat high blood pressure) 20 milligrams (mg), one tablet daily (scheduled administration time 9:00 A.M.) and Baclofen (medication used to treat muscle spasms) 10 mg, one tablet twice daily (BID) (scheduled administration times 9:00 A.M. and 1:00 P.M.). [...]

Inspectors wroteBased on observation and interview, the facility failed to provide a dignified and homelike dining experience for residents who dined in the second and third floor dining rooms by leaving the plates and glasses on cafeteria style trays and leaving plate lids on the tables during meals. The sample size was 15. The census was 59. 1. Observations on 10/7/19 at 11:18 A.M., 10/8/19 at 7:53 A.M., 10/9/19 at 7:39 A.M., 10/10/19 at 8:00 A.M. and 10/11/19 at 7:43 A.M., showed residents seated at the dining room tables on the second floor. Staff served the meals on trays and did not remove the cafeteria style trays from beneath the plates. 2. Observations on 10/7/19 at 11:18 A.M., 10/8/19 at 7:43 A.M., 10/9/19 at 7:35 A.M. and 12:20 P.M., 10/10/19 at 7:34 A.M. and 10/11/19 at 7:14 A.M., showed residents seated at the dining room tables on the third floor. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide written notice of the facility's bed hold policy to residents or their legal representatives, at the time of the transfers, for six of 15 sampled residents who were transferred to the hospital for medical reasons (Residents #12, #46, #40, #45, #41 and #22). The census was 59. Review of the facility's Bed-Hold and Return policy, revised in March 2017, showed prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. 1. Review of Resident #12's medical record, showed the following: -admission date of 7/9/09; -Order to discharge to hospital 8/31/19; -readmission to facility 9/2/19; -No documentation the resident and/or their representative received written notice of the facility's bed hold policy at the time of the transfer. 2. [...]