Eastview Manor Care Center

Inspectors wroteBased on interview and record review, the facility failed to protect one resident (Resident #1) from physical abuse when Certified Nurse Aide (CNA) A pushed into the resident's chest using his/her chest and then grabbed the resident by both arms and pushed the resident to a seated position in a chair and then used his/her hands to hold the resident in place until other staff intervened. Additionally, the facility failed to keep one resident (Resident #4) in the building free from verbal threats of abuse from Resident #1, when Resident #1 threatened to kill Resident #4 with a broken hanger. This affected two of six sampled residents, the facility census was 84. On 07/29/26 , the Administrator was notified of the past noncompliance incident which occurred on 07/25/26, An investigation immediately began and corrective actions were implemented to include: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents were allowed to exercise their right to make personal choices regarding their dietary preferences when facility staff limited residents to a maximum of two packets of each condiment per meal and depleted inventory of cold cereal, brown sugar and cottage cheese. This affected three out of the six sampled residents. The facility census was 80. Review of facilities policy titled Promoting/Maintaining Resident Dignity dated 09/21/25 showed the resident's personal choices will be considered when providing services to meet the resident's needs and preferences. Review of facility's policy titled Resident's Rights dated 09/21/25 showed residents had the right receive services with reasonable accommodations of individual preferences. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure two residents were treated with dignity and respect when the facility allowed staff to speak to cognitively impaired residents with disrespectful tone. This affected two residents (Resident #4 and #5) out of six sampled residents. The facility census was 80. Review of facility's Promoting/Maintaining Resident Dignity policy, dated 09/21/25 showed:-All staff should treat residents with dignity and respect.-Staff should speak respectfully to residents. 1. Review of Resident #4's Quarterly minimum data set (MDS), A federally mandated assessment tool completed by staff, dated 04/12/26 showed:-Not Cognitively intact;-Diagnoses included: Traumatic brain injury, dementia, major depressive disorder, schizoaffective disorder, profound intellectual disabilities. Review of care plan dated 04/09/26 showed: [...]

Inspectors wroteBased on interview and record review, the facility staff failed to follow facility policy and ensure the residents physician was verbally notified on 01/21/2026 of a resident fall with a head injury and on 1/24/2026 when staff found the resident unresponsive for about a minute and with seizure like activity for about 45 seconds before becoming responsive again. The staff notified the residents physician on 01/25/26 at 12P.M., approximately 16 hours after the change in condition occurred. The facility census was 82. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect one resident's right, (Resident #4), to be free from abuse when Resident #3 hit Resident #4 on the left side of his/her ear. This affected one of the four sampled residents, (Resident #4). The facility census was 84. On 2/6/26 the Administrator was notified of the past noncompliance that began on 02/02/26. The facility administration immediately conducted aninvestigation and corrective actions were implemented that included in-service for all staff regarding abuse prevention, incidents and accidents and behavioral monitoring. The noncompliance was corrected on 02/04/2026. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a sanitary and comfortable environment was maintained in the secured unit when staff did not maintain one of two-unit showers observed to have a slimy black-mold like substance, did not ensure showers/tubs were cleaned between residents, did not repair the ceiling is need of repair, and did not maintain an effective pest-control system. This affected three of four sampled residents (Resident #1, #2, #3) The facility census was 81. Review of the facility's undated admission Packet showed basic covered services for all residents includes housekeeping and maintenance services. [...]

Inspectors wroteBased on interview and record review, the facility failed to allow one sampled resident to return to the facility when he/she did not meet criteria for hospitalization. Between 7/31/25 -8/1/2025 the resident was transported 5 times between 2 hospitals and the facility and on 8/1/25 was left stranded at the hospital with no clothes, money or personal belongings. The resident was without long-term care placement for approximately 9 days when he/she exhibited behaviors, requiring hospital staff to utilize restraints and admit the resident for psychiatric care. The facility census was 85. Review of the facility's Resident Transfer/Discharge/Immediate Discharge, and Therapeutic Leave Policy, dated 4/28/25., included: Residents who are sent emergently to the hospital are considered transfers because the residents return is generally expected. [...]

Inspectors wroteBased on interviews and record review, the facility failed to provide timely an appropriate discharge when staff failed to provide written notice of discharge that included the date and location the resident would be discharge to, statement of appeal rights and the name, address, or telephone number of the Office of the State Long Term Care Ombudsman (advocates for the residents in nursing facilities). The facility's census was 85. Review of the facility's Resident Transfer/Discharge/Immediate Discharge, and Therapeutic Leave Policy, dated 4/28/25., showed:-Notice of discharge or transfer must notify the resident and the resident's representative of the reason for discharge in a writing and must notify a representative of the Office of the State Long-Term Care Ombudsman at least 30 days in advance of the discharge or as soon as possible. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to protect one resident (Resident #1) from physical abuse when another resident (Resident #2) grabbed Resident #1 by the back of the shirt and hair, causing Resident #1 to lose his/her balance and fall to the ground. Resident #2 then made closed hand contact with Resident #1's face. The facility's census was 81. Review of the facility policy titled, Abuse and Neglect Policy, dated 6/12/24, showed: -It is the policy of the this facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the Administrator of the facility and to other appropriate agencies with current state and federal regulations within prescribed time frames; [...]

Inspectors wroteBased on interview and record review, the facility failed to protect three residents (Resident #29, #30, and #33) from physical abuse when Resident #1 strangled and punched Resident #30 in the face to the extent hospitalization was required; strangled and punched Resident #33 in the face resulting in medical evaluation at the local hospital; and took Resident #29's walker away and shoved the resident in the face, causing a fall that required the resident to have an x-ray for a large abrasion sustained to his/her left knee. The facility census was 81. The Administrator was notified on 04/18/2024 at 5:05 PM of the past noncompliance Immediate Jeopardy (IJ) which began on 03/21/2025. The facility administration immediately separated and protected the residents from further abuse by Resident #1. [...]

Inspectors wrote2. Review of Resident #56's annual MDS, dated [DATE], showed: -Moderate cognitive impairment; -Upper and lower body impairment on one side of the body; -Dependent on staff for toileting; -Diagnoses included: Stroke, diabetes, and depression. Review of the resident's care plan dated 02/27/25, showed: -ADL self-care deficit related to stroke; -Used a wheelchair; -Required assistance of two staff for ADLs; Observation on 04/01/25 at 09:49 A.M., showed: -The resident asleep, in a wheelchair, seated at a table in the dining room; -The resident was not wearing pants; -The resident's bare legs were exposed thigh down to his/her feet, because the resident's blanket was not pulled up; -NA J walked past the resident and did not cover up the resident's exposed areas. Other staff walked by and other residents were seated in the dining room. [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct pre-employment screenings per facility policy. The facility failed to check the certified nurse aide (CNA) registry prior to employment to ensure all newly hired employees did not have a Federal Indicator (marker given to individuals who have committed abuse/neglect), and the facility was unable to show they had completed a criminal background check (CBC) or employee disqualification list (EDL) check prior to employment. This affected 7 out of 7 sampled employees hired since March 2024. The facility census was 81. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident and resident representative, if applicable, was involved in developing the care plan and making decisions about his or her care. This affected 3 out of 18 sampled residents (Resident #9, #47, and #59). The facility census was 81. Review of the Facility's Comprehensive Care Plan Policy, revised 10/31/2024, showed: The purpose of a care plan is to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident's rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to: A. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff failed to ensure they provided perineal care at least every two hours for three residents (Resident #56, #8, and #59), The facility census was 81. The facility did not provide the requested policy on ADLs. Review of the facility policy Perineal Care, dated 06/29/23, showed: -Ensure residents' perineal area is kept clean to prevent skin breakdown, odor, and infection; -Perineal care is very important to maintaining the comfort of residents; -More frequent care is required for residents who are incontinent and for those who have an indwelling catheter. 1. Review of Resident #56's care plan dated 02/27/24, showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently provide a program of meaningful activities in accordance with the resident's preferences for six residents (Resident #59, #47, #48, #78, #43, and #29) of 18 residents. The facility census was 81. The facility Therapeutic Activities policy and scheduled activity calendar was requested and neither were provided. 1. Review of Resident's #59's Annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/24/24, showed the activity section of the MDS was not completed. Review of Resident #59's Quarterly MDS, dated [DATE], showed: -Cognition severely impaired. -Dependent in all activities of daily living (ADLs). -Diagnoses of Diabetes Mellitus and stroke. Review of the resident's care plan, dated 07/11/2024, showed: -Limited physical mobility. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident: when there was minimal oversight by nursing staff on the secured unit resulting in resident to resident abuse, when one resident (Resident #1) physically assaulted three residents (Resident #30, #33, and #29); the facility failed to ensure the facility had enough staff to provide perineal care at least every two hours to dependent residents who were unable to carry out activities of daily living (ADLs) for three residents (Resident #56, #8, and #59); [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure four nurse aides currently working and providing direct resident care met the minimum qualifications, which included satisfactory participation in a state-approved nurse aide training and competency evaluation program within four months of hire. The facility census was 81. Review of the facility's policy titled, Nurse Aide (NA) Qualifications and Training Requirements, revised May, 2019, showed: - Nurse Aides must undergo a state-approved training program; - In keeping with the Omnibus Budget Reconciliation Act of 1987 (OBRA), our facility will only employ those nurse aides who meet the requirements set forth in the federal and state statutes concerning the staffing of long-term care facilities; [...]

Inspectors wroteBased on interview and record review, the facility failed to follow infection control policy and procedures when the facility did not complete initial TB skin test procedures (Tuberculosis Testing-A skin test to check for active Tuberculosis- a serious bacterial respiratory infection that is highly transmissible) on newly hired employees, failed to read the TB skin test, and failed to document the results in the employee record or facility TB test book. This affected eight newly hired employees from March of 2024 through March of 2025. The facility census was 81. Review of the facility's Tuberculosis Testing policy, dated 4/28/23, showed: upon hire, a new employee will receive a 2 step TB skin test to ensure any possible TB infection can be proactively managed to prevent further spread. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to develop and implement a comprehensive person-centered care plan for three residents (Resident #38, #43, and #50). This affected three of 18 sampled residents. The facility census was 81. Review of the facility's Comprehensive Care Plan Policy, dated 10/31/24, showed: - The facility will develop and implement a comprehensive person-centered care plan for each resident. - The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. - The care plan will describe, at a minimum, the services that are furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Review of the facility's Oxygen Administration policy, dated 05/18/24, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain a physician order and care plan for hospice services for one sampled resident (Resident #8). The facility census was 81 residents. Review of the facility's Comprehensive Care Plan Policy, dated 10/31/24, showed: - The facility will develop and implement a comprehensive person-centered care plan for each resident. - The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. - The care plan will describe, at a minimum, the services that are furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse when four residents were involved in physical altercations (Resident #1, #2, #3 and #4). The facility failed to protect Resident #1 from physical abuse on [DATE] at 12:44 P.M. when Resident #2 open handedly applied for to Resident #1's shoulders causing resident to loose balance and land on bottom. The facility also failed to protect Resident #3 from physical abuse on [DATE] at 5:04 P.M. when Resident #4 open handedly applied force to Resident #3's chest resulting in resident #3 loosing balance and falling to the ground. The facility's census was 83. On [DATE] the Administrator was notified of the past noncompliance which began on [DATE]. The facility administration immediately conducted an investigation and corrective actions were implemented. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate treatment and services for one out of three residents (Resident #1) with behavioral health needs, including verbal aggression toward residents and staff, threatening other residents, physical altercations, and throwing objects. On 11/2/24 , the resident required one on one supervision after an incident of aggression. The resident was removed from one-on-one supervision, without input of the Interdisciplinary Team (IDT) on 11/4/24, and placed on 15 minute checks. No other interventions were put into place and on 11/9/24 the resident had another aggressive outburst- striking another resident. The facility census was 82 Review of the Facility Assessment, dated 11/15/24, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow the facility's policies to notify the physician and obtain physician orders when pressure ulcers were found, continue to conduct and document assessments of the wounds, and notify the physician of accurate descriptions and deterioration of the wounds for one resident (Residents #1) who developed a large unstageable pressure ulcer. Additionally, the facility failed to notify the physician and obtain orders for an open area over the bony prominence of one resident's (Resident #2) coccyx and conduct and document assessments of the resident's wound per policy. The facility census was 84. The Administrator was notified on 10/25/24 at 5:54 P.M. of an Immediate Jeopardy (IJ) which began on 10/02/24. The IJ was removed on 10/31/24 as confirmed by surveyor onsite verification. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide supervision to prevent an accident for one resident (Resident #1), when on [DATE] staff transferred the resident into a transport wheelchair (a wheelchair designed for short-term use) and left the resident unsupervised. Approximately ten minutes later, the resident was found face down on the floor in a pool of blood with his/her bottom sitting on his/her feet and forehead against the floor. The resident was sent to the hospital, sustained bleeding in his/her brain and was placed on end of life care on [DATE]. The resident passed away while at the hospital on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the responsible party or physician of a change in condition for four residents (Residents #1, #3, #4, and #5). The facility census was 84. Review of the facility Notification of Changes policy, dated 2023, showed: -The purpose of the policy is to ensure the facility promptly informs the resident, consults the resident's physician and notifies, consistent with his/her authority, the resident's representative when there is a change requiring notification. -The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member/legal representative when there is a change requiring notification, such as: --Accidents resulting in injury or have the potential to require physician intervention; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the wound nurse had the appropriate competency and skill set, when one resident's (Resident #1) wound was not appropriately identified, assessed, and treated. The facility census was 84. The facility did not provide a job description or requirements for the Wound Nurse (WN). Review of the facility's undated Wound Treatment Management Policy showed: -The purpose of the policy is to promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three of three sampled nurse aides (NA) were enrolled in a state-approved training and competency evaluation program and completed a nurse aide training program within four months of his/her employment in the facility. The census was 84. The facility did not provide a policy on education and Certified Nurse Aide (CNA) training. The facility did not provide a policy for the Hall Monitor position. Review of the facility's Hall Monitor Job Description, dated 9/17/24, showed: -The Hall Monitor position is a way to ensure there is extra support within the facility to help assist with non-nursing duties. -Duties: [...]

Inspectors wroteBased on interview and record review, the facility staff failed to follow policy and report an injury of unknown origin to the administrator or state survey agency when Licensed Practical Nurse (LPN) A discovered one resident (Resident #1) to have multiple bruises of unknown origin on or about 10/13/2024 on the resident's sides and lower breasts. The facility census was 84. Review of the facility's Abuse and Neglect policy, dated 9/17/2024, showed: -It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed timelines. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow facility policy and investigate an injury of unknown origin when staff discovered one resident, (Resident #1) with multiple bruises of unknown origin on the resident's sides and lower breasts. The facility census was 84. Review of the facility's Abuse and Neglect policy, dated 9/17/2024, showed: -Injuries of an unknown source includes circumstances when both the following conditions are met: The source of the injury was not observed by any person or could not be explained by the resident. The injury is suspicious because of the extent of the injury, location of the injury, the number of injuries observed at one particular point in time, or the incidence of injuries over time. -Guidelines: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to protect two residents (Resident #3 and Resident #5) that reside on the secure unit from abuse by Resident #1. Residents #3 and #5 were hit in the head by Resident #1. Resident #2 said residents feel they have to walk on eggshells on the unit, because they do not know when Resident #1, will become upset and lash out verbally or physically. Resident #2 stated he/she feels staff are unable to protect others from Resident #1. Resident #3 said he/she does not feel safe in the facility due to Resident #1's verbal and physical abuse to him/her and the other residents. Resident #4 said he/she does not feel safe because the other residents on the secure unit have too many behaviors and do whatever they want on the unit. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate education and ensure staff were competent to provide care and protection to residents with mental and behavioral health diagnoses, when Resident #1, who resided on the secured special care unit, had multiple physical altercations with other residents, causing physical injury and emotional distress to other residents. Additionally, Resident #6 engaged in self-harming behaviors, causing lacerations to his/her forearms and upper legs. Staff were unaware of non-pharmacological interventions, individual care plan interventions, and were unable to provide appropriate protection, as no education was provided to them prior to assignment on the special care unit for behavioral health. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate treatment and services to address the behavioral health needs of two residents (Resident #1 and #6) to attain the highest practicable mental and psychosocial well-being. This is evidenced by Resident #1, who requires behavioral health support needs and has a history of physically abusive behaviors, abusing two residents (Residents #3 and #5) on the secure care community, as a result of the facility failure to assess and implement appropriate interventions to address their behavioral health needs. Additionally, Resident #6 displayed self-harming behaviors and the facility failed to assess behavioral support needs and implement appropriate interventions to address the self-harming behaviors and ensure their safety. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three residents (Residents #14, #15, #16) were free from misappropriation when a staff member (Hall Monitor A) took their medications. Law enforcement found the medications in Hall Monitor A's possession when they executed a search warrant at his/her home. The facility census was 87. Review of the facility's Abuse and Neglect policy, dated 9/17/2024, included: Misappropriation of Resident Property: The deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent, including resident's medication. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide appropriate treatment and services to maintain or improve resident abilities to carry out activities of daily living, including dressing, shaving, grooming, and bathing for four of 13 sampled residents (Residents #7, #10, #11, and #13). Each of the residents were assessed and care planned as independent with activities of daily living, however, residents were observed with greasy hair, dirty clothing, body odor, and long, dirty nails. The facility census was 87. Review of the facility's Activities of Daily Living (ADL) Policy, dated 9/17/24, showed: -The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance with activities of daily living to three of 13 sampled residents (Resident#8, #9, and #12 ), who were unable to perform their own in order to maintain good personal hygiene. Each of the residents were assessed and care planned as dependent on staff for activities of daily living, however, residents were observed with greasy hair, dirty clothing, body odor, and long, dirty nails,and ungroomed facial hair. The facility census was 87. Review of the facility's Activities of Daily Living (ADL) Poliy, dated 9/17/24, showed: -The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide a clean, odor free and comfortable environment. Strong odors of urine and body odor were present, floors in entry way and dining rooms were sticky and had spilled drinks and food on them, and there was evidence of flies and mice. A resident's air conditioner had dark colored mold on it. The facility census was 87. Review of the facility's Nursing Environmental Inspection Policy, dated 9/17/24, showed: -It is the policy of this facility to regularly monitor the nursing services environment to ensure the facility is maintained in a safe and sanitary manner. -1. The Director of Nursing or designee will perform random and/or routine inspections of the nursing environment. These areas of inspection will consist of, but is not limited to: a. Resident Rooms b. Medications rooms and medications carts c. Resident Common Areas d. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #7) had safe and well-maintained assistive devices to prevent accidents. The resident used a manual wheelchair for independent mobility. The wheelchair was not safe and functional. The resident could not lean back in it for fear of falling over due to the back support being worn out. The facility census was 87. The facility did not provide a policy regarding ensuring resident's assistive devices are well maintained and safe. 1. Review of Resident #7's admission Minimum Data Set (MDS, a federally mandated assessment completed by staff), dated 6/27/24, showed: -The resident was originally admitted to the facility on [DATE]; [...]

Inspectors wroteRefer to Event ID N5TM12 Based on observation, interview and record review, the facility failed exercise reasonable care for the protection of resident's property to prevent loss or theft when staff did not ensure resident property was accounted for, labeled and/or returned to the resident. This impacted six of six surveyed residents (Residents #1, #2, #3 and #5) The facility census was 88. Review of facility policy, Safe and Homelike Environment Policy, dated 2024, showed: -In accordance with resident's rights, the facility will provide a safe, clean, comfortable, and homelike environment, allowing the residents to use his or her personal belongings to the extent possible. - The facility staff should exercise reasonable care for the protection of the resident's property from loss or theft. Review of facility policy, resident rights, dated 2024, showed: [...]

Inspectors wroteRefer to event ID N5TM12 Based on observation, interview, and record review, the facility failed to ensure residents received the necessary services to maintain good grooming and personal hygiene when showers were not provided twice a week which affected four residents (Resident #1, #2, #5, and #6) of six sampled residents. The facility census was 88. Review of facility policy, activities of daily living (ADL), dated 2024, showed: -The facility will, based on the resident's comprehensive assessment and consistent with resident's needs and choices, ensure a resident's abilities in ADLS do not deteriorate unless deterioration is unavoidable. -Care and services will be provided for the following activities of daily living: 1. [...]

Inspectors wroteBased on observation, record review, and interview the facility failed to prepare and serve food in accordance with professional standards for food service safety when staff failed to keep a clean kitchen, failed to temperature check foods, failed to maintain foods at a safe holding temperature during food service, failed to store pitchers inverted, failed to keep food preparation surface free from staff personal items, failed to maintain the faucet temperature at a comfortable temperature, and failed to ensure staff washed their hands when contaminated. The facility census was 85. 1. Review of facility policy, food temperatures, dated 2024, showed: -Foods will be served at proper temperature to ensure food safety; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed exercise reasonable care for the protection of resident's property to prevent loss or theft when staff did not ensure resident property was accounted for, labeled and/or returned to the resident. This impacted six of six surveyed residents (Residents #1, #2, #3 and #5) The facility census was 88. Review of facility policy, Safe and Homelike Environment Policy, dated 2024, showed: -In accordance with resident's rights, the facility will provide a safe, clean, comfortable, and homelike environment, allowing the residents to use his or her personal belongings to the extent possible. - The facility staff should exercise reasonable care for the protection of the resident's property from loss or theft. Review of facility policy, resident rights, dated 2024, showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received the necessary services to maintain good grooming and personal hygiene when showers were not provided twice a week which affected four residents (Resident #1, #2, #5, and #6) of six sampled residents. The facility census was 88. Review of facility policy, activities of daily living (ADL), dated 2024, showed: -The facility will, based on the resident's comprehensive assessment and consistent with resident's needs and choices, ensure a resident's abilities in ADLS do not deteriorate unless deterioration is unavoidable. -Care and services will be provided for the following activities of daily living: 1. [...]

Inspectors wroteBased on observation, interviews, and record review, the staff failed to ensure residents remained free from accident hazards and failed to provide adequate supervision to prevent accidents when a dedicated staff member who was responsible for providing one on one supervision to one resident (Resident #1) did not keep resident within eyesight and he/she was able to tie a string around his/her neck while using the bathroom. The facility census was 85. Review of facility policy, accidents and supervision policy, dated 2024, includes the resident environment will remain as free of accident hazards as possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. Review of facility policy, intensive monitoring, dated 2024, showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure they cared for residents in a dignified manner when staff failed to change a resident's (Resident #44) clothes for four days. The facility also failed to serve all resident's meals in a dignified manner by leaving all meals on meal trays during each observed dining experience. This had the potential to affect all sampled residents. The facility census was 83. Review of the facility's Dignity and Respect policy, dated 6/29/23 showed: - The purpose of the policy was to ensure that every resident is treated with dignity and respect; - All staff will speak to and treat all residents with dignity and respect. 1. Review of Resident # 44's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/11/23 showed: [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to respect the dignity of six sampled residents (Residents #12, Resident #14, Resident #18, Resident #45, Resident #54 and Resident #70) when dietary staff yelled out to the residents in an undignified manner during lunch, and when the staff did not ask the residents if they would like to have their plates removed from the serving tray before eating and when the facilty made the residents set at at assigned tables. The facility census was 83. Review of the facility's Resident Rights policy, revised, 7/5//23, showed: -The resident has the right to a dignified exorbitance, self-determination; -The facility must protect and promote rights of each resident. 1. Observation on 2/6/24 at 1:10 P.M., showed: - The residents sat at assigned tables in the dining room on Station 2; [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to create an environment respectful of the rights of each resident to make choices about significant aspects of their lives. Facility staff failed to allow non-smoking residents to go outside and get exercise separately from the residents who smoked, which affected three of 18 sampled residents, (Resident #27, Resident #45 and Resident #70) and the facility staff only allowed residents who reside on the secure unit to have three drinks at a meal which affected all 38 residents on the secure unit. The facility census was 83. The facility did not provide a policy for resident's preferences. 1. Review of Resident #70's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/31/23, showed: - Cognitive skills intact; - Did not indicate the resident smoked; [...]

Inspectors wroteBased on interviews and record review, the facility failed to act promptly and resolve resident grievances voiced during the resident council meetings. The facility did not maintain documentation of resident concerns, attempts to resolve concerns or follow up actions. The facility census was 83. Review of the facility's residents grievance policy, revised 9/25/23, showed, in part: - The facility wants to hear and address any concerns of a resident. A resident or their legal representative can bring concerns to a staff member, the resident concern group, or call the compliance hotline; - Every resident has the right to voice their grievance with the facility or other agency. Grievances could include care and treatment that was not provided, behavior or staff or other residents, or any other concerns regarding their stay; [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure they maintained a surety bond in an amount to cover any loss of theft to residents money held in the facility resident trust fund account which affected all residents who had money held in their Resident Trust Fund account. The facility census was 83. Review of the facility's approved Bond letter dated 9/20/23., included: - The Bond provides coverage in the amount of $75,000.00. The surety bond is required to be in an amount equal to one and one-half times the average monthly balance or average total of the balances, rounded to the nearest one thousand dollars, in the residents' personal funds accounts for the preceding year. Review of the facility's 12 month resident interest bearing trust account on 2/9/24., showed: [...]

Inspectors wroteBased on observations and interviews the facility failed to ensure the residents had access to a telephone where the residents could make and receive calls in private. This affected three of 18 sampled residents, Residents #42, Resident #53, and Resident #69. The facility census was 83. Review of the facility's Resident Rights Policy dated 2024, showed: -The residents have the right to reasonable access to the use of a telephone, where calls can be made without being overheard. 1. Review of Resident #42's admission Record, Face Sheet dated 9/8/23/, showed: - Age-28; - Under Guardianship through [NAME] County Public Administrator Office; - Diagnoses: Schizophrenia (A disorder that affects a person's ability to think, feel, and behave clearly.), anxiety, depression, history of illegal drug use. Review of Resident #42's revised care plan, dated 11/14/23., showed: [...]

Inspectors wroteBased on observation and interviews, the facility failed to maintain a clean and comfortable homelike environment when staff failed to properly clean resident room floors, prevent strong odors in resident rooms and halls, clean visible debris from exposed plumbing, replace cracked glass at the end of a resident hall way, maintain and clean flooring in the front dining area, replace and repaint areas of missing paint in resident rooms, ensure all resident lighting fixtures had a globe, and provide a furnished common area on a locked unit. This had the potential to affect all residents. The facility census was 83. Review of the facility's Housekeeping- Deep cleaning policy, dated 6/29/23 showed: - The purpose of the policy is to ensure all rooms are clean; - Deep cleaning was to be completed) as scheduled; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the admissions policy did not require residents or potential residents to waive potential facility liability for losses of personal property. The facility census was 83. Review of the facility's admission policy showed a section titled Personal Possessions on page 13 which contained the following the facility shall under no circumstances be held responsible for or have any liability of any nature whatsoever for loss or damage to valuables, personal property or money brought to facility. During an interview on 2/9/24 at 5:45 P.M., the Administrator said he was aware the admission agreement contained this stipulation. The Administrator said he did not realize this was related to a regulation.

Inspectors wroteBased on observation, interviews and record review, the facility failed to meet professional standards of care when the facility staff failed to obtain and update orders for Prothrombin Time Tests (PT) (a test that measures how long it takes for a clot to form in a blood sample and international normalized ratio (INR) (a type of calculation based on PT test results) checks for a resident receiving Coumadin (Resident #44), obtain clear orders for a resident (Resident #44) receiving Coumadin (a blood thinner), and set up a follow up appointment as prescribed by a nurse practitioner for Resident # 52. This affected 2 of 18 sampled residents. The facility census was 83. Review of the facility's Transcription of Orders/Following Physician's Orders policy. Dated 9/20/23 showed: [...]

Inspectors wroteBased on interviews and record review the facility failed to provide meaningful activities, including religious services and outdoor activities to three sampled residents, Resident #60, Resident 52 and Resident #136, that reside on the Special Care Unit. In addition, 10 of 10 residents in a group meeting reported meaningful activities were not being provided. The facility census was 83. Review of the Activity policy with a revision date of July 19, 2023 includes; - The purpose of this policy is to ensure that all residents in the facility are provided an ongoing program of activities designated to meet, in accordance with comprehensive assessment, their interests and their physical , mental and psychosocial-social well-being. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide trauma informed care to three sampled residents (Resident #45, Resident #71 and Resident #83) with a diagnosis of Post-Traumatic Stress Disorder (PTSD, a mental health condition that is triggered by a terrifying event). The facility census was 83. The facility did not provide the requested Trauma Informed Care policy. 1. Review of Resident #45's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -No cognitive impairment; -The resident is independent with Activities of Daily Living (ADLs): -Doing things with groups of people is very important to the resident; -Doing favorite activities is very important to the resident; [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure staff administered medications with a medication rate of less than five percent (5%). Facility staff made seven medication errors out of 25 opportunities for error resulting in a medication error rate of 28% which affected five of 18 sampled residents, (Resident #19, Resident #30, Resident #31, Resident #54 and Resident #83). The facility census was 83. Review of the facility's policy for medication administration and monitoring, revised 9/20/23, showed, in part: - The purpose is to ensure a process is in place for proper administration of medications, techniques of administering medications, effective monitoring of residents for adverse consequences associated with side effects to medications. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure staff provided a safe and effective medication administration system that was free of significant medication errors when staff failed to prime the insulin pens prior to administering the insulin which affected two residents, (Resident #54 and Resident #83). The facility census was 83 Review of the facility's policy for guidance for using insulin products, dated 2021, showed, in part: - To minimize air bubbles in pen-like devices prime the pen prior to each and every injection by pushing two units into the air until a drop of insulin is seen at the top of the needle. Review of the manufacturer's guidelines for Lantus (long acting) flexpen insulin, revised 2022, showed; - Dial a test dose of two units; -Press the injection button all the way in and check to see that insulin comes out of the needle; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare food by methods that conserve flavor and appearance when residents were served hamburgers and cheeseburgers that failed to maintain palatable flavor and appetizing appearance. This had the potential to affect all residents. The facility census was 83. Review of the facility's Dietary Food Preparation policy, dated 7/5/23 showed: - Standardized recipes will be used for all products prepared; - The cook and/or the dietary manager will taste food prepared before serving; - Foods will be served at proper temperature to insure food safety; - No instructions to ensure food is cooked in a manor to conserve flavor and appearance. 1. Review of Resident # 44's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/11/23 showed: [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed prepare and serve food in accordance with professional standards for food service safety when staff failed to store food in a sanitary manner and failed to maintain the kitchen in a sanitary manner. This has the potential to affect all residents residing in the facility. The facility census was 83. Review of the facility's Dietary Equipment Operations, Infection Control, and Sanitation Policy, dated 2/2/24 showed: - The dietary staff shall maintain the sanitation of the dietary department through compliance with written, comprehensive cleaning schedules developed for the facility by the dietary manager; - All surfaces and equipment shall be washed with a sanitizing solution; - The dish machine will be cleaned after each meal; - Weekly cleaning of dish machine interior and exterior with de-liming solution; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide documentation that the Quality Assessment and Assurance (QAA) met on a quarterly basis and included the appropriate attendees; failed to identify, develop, implement, monitor and evaluate system problems. This had the potential to affect all residents. The facility census was 83. Review of the facility's undated Quality Assurance Performance Improvement (QAPI) plan showed: - Purpose: to provide quality excellence in resident care and do a root cause analysis for identified areas of concern and improvement; - The QAA committee will review data from areas the facility believes it needs to monitor on a monthly basis to assure systems are being monitored and maintained to achieve the highest level of quality for our organization. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow acceptable infection prevention and control practices to help prevent the development the transmission of communicable diseases and infections when staff failed to change gloves and failed to sanitize shared medical equipment using acceptable standards of practice effecting two residents (Resident #8 and Resident #13) of the 18 sampled residents, and failed to follow their new employee policy regarding infection control practices and Tuberculosis Screening for eight of the 10 sampled new hires. The facility census was 83. Facility policy regarding Handwashing, dated 6/29/23, showed: -Purpose: To provide guidelines to employees for proper and appropriate handwashing techniques that will aid in the prevention of the transmission of infection. Handwashing is indicated and should be performed when: [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADL) received the proper care to maintain good personal hygiene when facility staff did not provide complete and thorough perineal care, as well as provide fingernail hygiene. This affected one resident (Resident #8) of five sampled residents. The facility census was 83. The facility did not provide a policy for ADL care for the dependent resident. 1. Review of Resident #8's Quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 1/13/24, showed: -Dependent on staff for personal hygiene, transfers, dressing and eating. -Incontinent of bladder. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the development of pressure ulcers, failed to identify pressure ulcers, as well as address risk factors for the development of pressure ulcers and failed to provide interventions to prevent pressure ulcers for one resident (Resident #8) of the five sampled residents. The facility census was 83. Review of the facility Pressure Ulcer Policy, dated 6/29/23 showed: A pressure ulcer is defined as an area of skin breakdown that develops when the skin and sort tissue is squeezed between the bones and the surface that is within contact of the body. This process reduces the flow of blood to the area and causes the area to lose necessary blood and oxygen vital for the body tissue to thrive. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assess pain and failed to provide pain management in accordance with the resident's physician orders for one resident (#13) of five sampled residents. The facility census was 83. Review of the facility's Pain Management policy, reviewed 7/5/22, showed: Purpose: The purpose of this policy is to ensure that all residents who are receiving routine scheduled pain medication or PRN (as needed) pain medication on a frequent basis have their pain evaluated and assessed prior to pain medication and within one hour after the medication was given to determine if the current pain medication regimen is effective to adequately manage the resident's acceptable pain level. [...]

Inspectors wroteBased on observations,record review, and interviews, the facility failed to ensure they posted in a conspicuous location and in a manner accessible to residents, resident representatives and vistors, a copy of the most current state licensure and annual certification survey results. The facility census was 83. Review of the facility's undated Resident Rights Policy., showed: -The residents of the facility have the right to examine the results of the most recent survey results conducted in the facility by Federal and State surveyors and any plan of correction in effect. During a Resident Council meeting on 2/7/24 at 10:00 A.M., the residents were unaware of the location of the last survey results for the facility. The residents in the secured female unit, were unaware of the survey results book or what is was. [...]

Inspectors wroteBased on record review and interview, the facility failed to assess, contact the physician, and treat timely one sampled resident (Resident #64) when he/she voiced complaints of being in pain from constipation and reported seeing blood when trying to have a bowel movement. The facility census was 83. 1. Review of Resident #64's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 3/18/21, included the following: - Date admitted [DATE]; - Cognitively intact; - Independent with toilet use; - Constipation section was not completed. Review of the resident's care plan, dated 4/4/21, did not show any information regarding a history of constipation. Review of the resident's May 2021 Physician Order Sheet included the following order: - Check for fecal impaction and remove as needed, order date 2/16/21; [...]

Inspectors wroteBased on observations, interview and record review, the facility failed to identify, assess and document, accurately and timely, a sacral pressure ulcer (PU), when the ulcer was first identified as a Stage 3 PU (Stage 3 is a full thickness tissue loss. Subcutaneous (the tissue between the fat layer just under the skin and over the top of the muscles) fat may be visible but bone, tendon or muscle is not exposed. Slough (dead tissue) may be present but does not obscure the depth of tissue loss. May include undermining (when the tissue under the wound edges becomes eroded, resulting in a a pocket beneath the skin at the wound's edge) and tunneling (channels that extend from a wound into and through subcutaneous tissue or muscle)and failed to follow physician's orders for treatment of sacral ulcer and right heel ulceration for one resident (Resident #7) of 22 sampled residents . [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to provide a safe, clean, comfortable and homelike environment for all residents of the facility, when staff did not keep rooms clean, floors throughout the building clean and in good repair, left dead mice in an empty cabinet on Station 2, shower rooms dirty with mold-like substances on the floors and walls, doors and walls in all the hallways and in resident rooms scuffed with missing paint, missing closet doors, cabinet drawers that did not close, failed to remove a dead and decaying bird from the main entrance walkway into the facility where visitors and residents entered and exited the building, and an overall uncleanliness about the building which affected all of the facility's five residence halls, all common areas of the facility and outside around the entire building. The facility census was 82. [...]

Inspectors wroteBased on observation, record review and interviews, the facility failed to prepare and serve food in accordance with professional standards for food service safety when staff failed keep a clean kitchen, failed to label food when it was opened, failed ensure each refrigerator and freezer had working thermometers and failed to ensure staff washed their hands as often as necessary. The facility also failed to ensure foods were refrigerated according to the manufacturer's recommendations. The facility census was 82. Review of the facility policy titled Dietary- Sanitary Procedures, dated 10/23/29, included the following: - Hand Washing and Glove Use: Hand washing is a priority for infection control. [...]

Inspectors wroteBased on observation and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public when they failed to keep areas around the facility free of trash, personal protective equipment (PPE), and other debris, and failed to maintain the lawn in the fenced in courtyard off Station 2. The facility census was 88. Observation on 5/3/21, starting at 9:30 A.M., showed a dead bird laying on the sidewalk leading into the main front entrance of the facility. The dead bird remained on the sidewalk until sometime after 11:30 A.M., on 5/4/21, when someone had scooted it out into the grass beside the sidewalk, about 6 inches from the walkway. Observations on 5/12/21, starting at 2:45 P.M., of the outside perimeter of the building showed: - Outside in the front resident smoking area, trash covered the grass around the area; [...]

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure staff treated residents in a manner to maintain their dignity when staff failed to maintain a covering for one sampled resident, (Resident #7), who was exposed from the waist up and visible from the hallway, failed to remove facial hair per the resident's preference for Resident #54, spoke to Residents #74 and #7 in a disrespectful manner, and failed to serve meals to residents at each table at the same time so they could enjoy their meal in a home-like atmosphere, which affected the female residents on the secure unit and failed to provide a dignity bag over the drainage bag for Resident #14. [...]

Inspectors wrote3. Review of Resident #42's annual MDS, dated [DATE] showed: -Brief interview for mental status (BIMS) score 15. This indicates no cognitive impairment; -Very important to have family involved in discussions about his/her care; -Diagnosis include Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), hypertension, schizophrenia, anxiety, chronic pain syndrome. Review of the resident's Care Plans showed: -admit date [DATE]; -Initial care plan dated 4/12/2021; -Revised care plan dated 4/12/2021; -Care plan problem -The resident has a guardian (with a phone number) to assist in decision making due to mental illness; -Desired outcomes-The guardian will assist in making decisions for the resident; -Interventions/Tasks -Ensure guardians wishes are followed. During an interview on 5/5/21 at 2:40 P.M., the resident said: [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to promote self-determination for two of twenty residents when staff failed to help two of 20 sampled residents (Resident #16 and #54) shave at least every other day, a choice about aspects of life he/her deemed significant and have those preferences care planned, failed to allow two sampled residents (Resident #35 and Resident #50) to go outside to get exercise, failed to assist one sampled resident (Resident #4) who wished to live in a less restrictive environment, and failed to provide seconds at meal times for the four sampled residents (Resident #14, #21, #84, and #74,). Facility census was 82. 1. The facility did not provide a policy for Activities of Daily Living (ADL). 2. Review of Resident #16's annual minimum data set (MDS, a federally mandated assessment completed by facility staff), dated 5/5/21 showed: [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to act promptly and resolve resident grievances voiced during the resident council meetings which were held by the Department Heads. The facility did not maintain documentation of resident concerns, attempts to resolve concerns or follow up actions. The facility census was 82. The facility did not provide a policy regarding resident council meetings. Review of the facility's grievance policy for residents, last revised 4/29/21, included: - The purpose is to set forth the resident's right to file a grievance and the process to be followed; - The facility wants to hear and address any concern of a resident. A resident or their legal representative can bring concerns to a staff member, the resident concern group, or call the compliance hotline. Additionally each resident has the right to use the formal grievance process; [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure they kept resident funds separate from the facility's operating account. This affected three additionally sampled residents. (Residents #26, #339, and #341). The facility also failed to provide quarterly statements to residents or legal representatives which affected three of 20 sampled resident (Resident #8, #68 and #84). The facility census was 82. Review of the facility policy titled Personal Items/Personal Funds, dated 4/6/17 included the following: - Purpose: to ensure that Resident Trust Fund are managed accurately to outline duties and responsibility; - Quarterly statements will be sound out to guardians by Social Service Director and hand delivered to the resident if they are responsible for self; Review of the facility policy titled Resident Trust, dated 3/1/2017, included the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide personal funds and a final accounting within thirty days upon discharge. This affected one additional sampled resident (Resident #340). Facility census was 82. Review of the facility polity titled Resident Trust, dated 3/1/17, included the following: - Handling the Funds of discharged Residents: Upon the discharge of a resident, the facility shall provide an up-to-date accounting of the resident's trust account balance and personal possessions; - The resident shall be issued a check for all remaining personal funds in his/her account within five (5) days of discharge. The Resident Trust Clerk shall provide a complete accounting record of the funds along with the check; - Checks received after a resident is discharged should either be forwarded to the resident or returned to the sender. [...]

Inspectors wroteBased on record review and interview, the facility failed to purchase a surety bond in a sufficient amount to assure the security of all residents' personal funds deposited with the facility. The facility census was 82. 1. Review of the facility policy titled Resident Trust, dated 3/1/17, showed the following: - The facility shall provide assurance of financial security by means of a surety bond. The bond shall be in an amount equal to at least one and one-half times the average total of the reconciled monthly balances. Review of the facility's surety bond dated September 2020 showed the bond was increased from $25,000 to $30,000. There was no approval letter from the Missouri Department of Health and Senior Services (DHSS) for this increased bond. Review of the DHSS approval letter dated 5/21/20 showed the approval for the $25,000 bond dated 3/9/20. [...]

Inspectors wroteBased on observation, record review and interviews, the facility failed to inform residents of their rights prior to or during admission and during the residents' stay. This affected all the residents who resided on Station Two. The facility census was 82. Review of the resident council meeting notes, dated 3/24/21, showed there were no documentation regarding rights reviewed with the residents. Observation on 5/3/21 at various times showed: - The residents' rights were not posted on Station Two. During a group interview on 5/4/21 at 10:23 A.M., the residents said the following: - The residents rights are not reviewed; - They thought their rights should be posted on the wall. During an interview on 5/5/21 at 2:50 P.M., Social Services said: - They did not go over the residents' rights during the resident council meetings. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide accessible information regarding the State Survey Agency that was readily available to residents who resided on Station Two. The census was 82. Review of resident's rights policy, revised 4/29/21, showed: - The purpose was to ensure resident rights are protected; - The facility must post the names, addresses, ant telephone numbers of all pertinent State client advocacy groups such as the State Survey and Certification agency, the State Licensure office, the State Ombudsman program, the Protection and Advocacy network, and the Medicaid fraud control unit; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure they updated the code status for two of 20 sampled residents (Residents #7 and #385) in order to ensure staff would respond appropriately in the event one of the residents was found unresponsive with no heartbeat, breathing, or pulse. Resident #385's medical record contained a signed Outside the Hospital Do Not Resuscitate (OHDNR) form and staff did not know this to be the resident's wishes and Resident #7 did not have the identifying black dot on his/her room door indicating to staff, the resident had a signed OHDNR. The facility census was 82. The facility did not provide a policy on Code Status. 1. Review of Resident #385's annual Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated [DATE], showed: [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to maintain complete records of resident council meetings, failed to provide anonymous easy access to the grievance forms on Station Two and the dietary manager failed to respond to verbal dietary concerns voiced by the residents on Station 2. This affected all the residents who reside on Station Two. The facility census was 82. 1. Review of the facility's grievance policy for residents, last revised 4/29/21, showed, in part: - The purpose is to set forth the resident's right to file a grievance and the process to be followed; - The facility wants to hear and address any concern of a resident. A resident or their legal representative can bring concerns to a staff member, the resident concern group, or call the compliance hotline. Additionally each resident has the right to use the formal grievance process; [...]

Inspectors wroteBased on record review and interview, the facility failed to run criminal background checks (CBC) and check the Nurse Aide (NA) Registry prior to hire. This affected four sampled staff. The facility census was 82. Review of the facility policy titled Screening- Applicant, Employee, Volunteer and Vendor (Missouri), dated 4/29/21, included the following: Pre-employment Screening: - Human Resources department (HR) will conduct pre-employment screens on applicants to determine whether the applicant has committed any disqualifying crime, is an excluded provider of any Federal or State healthcare programs, is eligible to work in the United States, and, if applicable, is duly licensed or certified to perform the duties of the position for which they applied; [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure staff developed, implemented, and updated a comprehensive, person centered care plan that included measurable objectives to meet the resident's needs, conditions, and risks for three residents (Resident #14, #69, #7) out of 22 sampled residents. The facility census was 82. 1. Review of the facility's comprehensive care plans and baseline care plans policy, revised 2/1/2020, showed, in part: - The purpose of this policy is to ensure that the facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment; - The comprehensive care plan must be completed within 14 days of admission; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow up on physician's pre-op orders to hold medications prior to a procedure for one resident (Resident #18) resulting in the procedure being re-scheduled. Facility staff failed to follow manufacturer's guidelines while administering Flonase to one resident (Resident #2). Facility staff did not obtain physician orders for accuchecks (blood glucose monitoring system) for one resident (Resident #8) or physician orders to clean or when to change a suprapubic catheter (a hollow flexible tube used to drain urine from the bladder, inserted into the bladder through a cut in the abdomen), for one resident (Resident#14). The facility census was 82. 1. Review of Resident #18's Minimum Data Set, (MDS a federally mandated assessment instrument completed by staff), dated 2/2/21, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who were unable to carry out their own activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff did not provide appropriate care of facial hair for Resident #54, clean fingernails for Resident #7 and provide oral care for Resident #59. The facility census was 82. The facility did not provide a policy for shaving the residents. The Director of Nursing (DON) stated that shaving was covered in Resident Rights. Review of Resident Rights, last revised 4/29/21, showed: Participate in Care: Resident will be informed by his physician of his/her health and medical condition and will be given the opportunity to participate in his/her care. [...]

Inspectors wrote6. Review of Resident #83's admission MDS, dated [DATE], showed: - Resident able to make daily decisions; - It was somewhat important to join in activities with groups of people; - It was very important to go outside when weather permitting; - It was very important to do his/her favorite activities; - Diagnoses included anxiety, depression, Bi-polar disorder and post-traumatic stress disorder (PTSD); Review of subsequent quarterly MDSs revealed staff did not code resident preferences in Activities. Review of the resident's care plan, dated 4/3/21, showed: - Resident will reside in least restrictive environment possible dependent on physical, emotional, psychosocial needs; - Encourage resident to become engaged in facility life through group activities, meals in dining room, and therapeutic groups if applicable to needs. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff administered medications with a medication error rate of less than 5%. Facility staff made three medication errors out of 26 opportunities for error, resulting in a medication error rate of 11.54%. This affected (Resident #39, #8 and #53). The facility census was 82. Review of the facility's Medication Administration and Monitoring Policy, dated 2/26/21, showed: - Medication is to be given per physician's order; - It is imperative that all medications are given using the seven rights to medication administration which includes: Right Medication, Right Dose and Right Dosage Form. The facility did not provide a policy for administration of rapid acting insulin in relationship to time of meal service. Review of the Flexpen manufacturer's guideline, dated May 2016 showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store drugs and biologicals in accordance to professional principles when prescription and over the counter expired medications for five residents (Residents #70, 6, 8, 29, and 38) were not removed from medication and treatment carts. All residents who took the over the counter medications were at risk as well. Facility census was 82. Review of facility policy, Monthly Inspections - Medications, dated 2/26/21, showed: -The purpose of this policy is to ensure that the facility is monitoring the labeling and storage of all medications within the facility on a routine monthly basis. -The facility will utilize a pharmacy consultant to review the facility's storage of medications. This will include inspections of the medication carts, treatment carts, and medication rooms. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to provide food in a form designed to meet individual needs when they did not ensure puree foods were at an appropriate consistency and failed to follow the recipe when making puree foods. The facility census was 82. Review of the facility policy titled Diets Policy, dated 10/23/19, included the following: - The facility will provide each resident with a regular or therapeutic diet, as ordered by the physician, in order to ensure that each resident receives the diet prescribed by the physician. The consistency of the diet shall also be ordered; - Dysphagia Puree- all foods shall be mixed in the blender to a pudding like consistency including breads and bakery products. Cream of rice is used in place of rice. Corn is avoided; [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to maintain medical records on each resident that are complete, organized, and readily accessible when a closed record for one out of two sampled residents (Resident #85) included records pertaining to at least thirty-eight other residents. Facility census was 82. Observation of the closed record review for Resident #85 pulled from storage located in the basement of the facility on 5/6/21 at 4:09 P.M. showed: -Fourteen other residents' consumption sheets for February 2021. -The February 2021 daily fridge temperature log for the medication room on unit 2. -Two other residents' individual patient narcotic records between January to March 2021. -Thirty-eight other residents' activities of daily living (ADL) sheets for February 2021 and ADL support provided documentation forms for February 2021. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the long term care (LTC) facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, as required when there was not a care plan created specifically for Hospice services and a Hospice chart was not in the facility for one of 20 sampled residents (Resident #385). The facility census was 82. The facility did not provide a policy on Hospice. 1. Review of Resident #385's annual Minimum Data Set (MDS, a federally mandated assessment completed by facility staff), dated 4/6/21 showed: -Brief interview for mental status (BIMS) score 14. This indicates no cognitive impairment. -Full code status; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment when staff failed to clean the COVID-19 (Coronavirus disease 2019, a contagious disease caused by severe acute respiratory syndrome coronavirus 2, symptoms may include fever, chills, fatigue, difficulty breathing, headache, loss of taste or smell, sore throat) screening tools which included a thermometer and pulse oximeter (a device placed on the finger that measure oxygen levels and heart rate) in between surveyors, failed to properly clean glucometer (blood glucose meter used to measure blood sugars) which affected Resident #47 and #65. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the exhaust system to remove bathroom odors. The facility census was 82. 1. Observation on 5/03/21 beginning at 11:10 A.M. showed the following rooms' bathrooms had exhaust vents that were caked with dust, dirt, and debris: - room [ROOM NUMBER], #24 and #25. The fan also made a loud noise when running in room [ROOM NUMBER]. - Exhaust vents in resident rooms 2, 9, 16, 26, and 32 were caked with dust, dirt and debris, as well as the vents in the 100 east shower room and the copyroom located on center hall. During an interview on 5/13/21 at 8:55 A.M. the Housekeeping Supervisor said maintenance used to vacuum the exhaust vents and the housekeeping would keep up with them. He/she was not sure who does them now. During an interview on 5/13/21 at 11:37 A.M. the Maintenance Supervisor said: [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure handrails were firmly affixed to the wall. The facility census was 82. 1. Observation on 5/3/21 at 11:10 A.M. showed the handrail outside of room [ROOM NUMBER] was loose when it was grabbed. Observation on 5/3/21 at 11:47 A.M. showed the handrail outside of room [ROOM NUMBER] was loose when it was grabbed. Observation on 5/5/21 at 9:54 A.M. showed the handrails outside the following rooms were loose when they were grabbed: - room [ROOM NUMBER], #5 (the end came apart from rail), #6, the room where the hard copy charts were being stored, outside Director of Nursing Office, #14, and #16. During an interview on 5/13/21 at 11:37 A.M. the Maintenance Supervisor said: - Work order forms for maintenance requests were kept at each nurses' station. The Maintenance Assistant would check them daily and work on them that day. [...]

Inspectors wroteBased on interviews, the facility failed to provide resident representatives, Ombudsman representatives, and other healthcare professionals access to residents when the facility failed to ensure phone calls to the main phone line were answered and/or messages returned timely. Facility census was 82. Review of facility policy, Resident's Rights, dated 4/29/21, showed: -Facility must provide immediate access to any resident by the State ombudsman. -Facility must provide reasonable access to any resident by any entity or individual that provides health, social, legal, or other services to resident. During an interview on 5/3/21 at 1:02 P.M. the Resident Care Coordinator B and Infection Control Nurse said with the Administrator and Director of Nursing present: -Phone calls will ring in all offices. There is not a designated receptionist. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure one of 20 sampled residents (Resident #8), had access to their funds at all times, including weekends. The facility census was 82. Review of the facility policy Personal Items/Personal Funds, dated 4/6/17, included the following: - Purpose: to ensure that Resident Trust Fund are managed accurately and do outline duties and responsibility; - All residents will have access to funds family excluding weekends and Holidays. Review of the facility policy titled Resident Trust, dated 3/1/17, included the following: - The facility shall allow the residents access to their personal possessions and funds during regular business hours, Monday through Friday. 1. Review of Resident #8's quarterly MDS, dated [DATE], included the following: - Date admitted [DATE]; - Cognitively intact. During an interview on 5/04/21 at 11:44 A.M. [...]

Inspectors wroteBased on observations and interviews, the facility failed to provide residents with reasonable access to a telephone when a resident broke the telephone, This affected the residents who resided on Station Two. The facility census was 82. 1. Review of the facility's resident's rights policy, revised 4/29/21, showed, in part: - Resident has the right tot have reasonable access tot he use of a telephone where calls can be made without being overheard. 2. Observation on 5/3/21 at various times throughout the day showed: - The private area for the residents on Station Two to make telephone calls did not have a telephone. 3. During the resident council meeting on 5/4/21 at 10:23 A.M., the residents said: - They did not have a telephone to use for private telephone calls, it was removed. 4. Review of Resident #14's admission MDS, dated [DATE], showed: Cognitive skills moderately impaired; [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure they received authorization from the resident/representative before utilizing bed alarms and placing a bed in low position, noting the understanding of the risks and the benefits of the interventions. The facility also failed to conduct ongoing assessments of the interventions. This affected one sampled resident (Resident #69) out of 20 sampled residents. The facility did not provide a policy regarding restraints. Review of the facility policy titled Resident Rights, dated 4/29/21, included the following: Freedom from Abuse - Resident has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat Resident's medical symptoms. Restraints may only be imposed: [...]

Inspectors wroteBased on record review and interviews, the facility failed to sure they contacted the guardian for one additionally sampled resident (Resident #45). Staff moved the resident to a sister facility without the guardian's approval, without providing a 30-day discharge notice to the guardian spelling out their right to appeal the discharge, the reason for the discharge, why they planned to discharge him/her, and where he/she would be transferred to after the discharge. The facility census was 82. Review of the Resident Transfer/Discharge, Immediate Discharge and Therapeutic Leave Policy, last revised on 4/29/21, showed: - The facility may discharge or transfer a resident as a facility initiated transfer or discharge for the following reasons: Resident's welfare and needs cannot be met by the facility. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure each resident received an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas and knowledgeable about the resident's status, needs, strengths, and areas of decline when one of 20 sampled residents (Resident #385) was placed on Hospice and the MDS (Minimum Data Set, a federally mandated assessment completed by facility) and care plan did not reflect the decline. One sampled resident's (Resident #69) MDS did not accurately show the resident's bowel and bladder functions or restraints. The facility census was 82. Review of the facility on policy on MDS on 4/6/21 showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement an effective discharge planning process and failed to have a complete discharge summary for one of two sampled residents (Resident #85) when the facility failed to have a discharge planning care plan, failed to document a final summary of the resident's status, failed to document a recapitulation of the resident's stay timely, and failed to show that all necessary information was provided to the receiving facility. Facility census was 82. Review of facility policy, Resident Transfer/Discharge, Immediate Discharge, and Therapeutic Leave policy, dated 4/29/21, showed: -Purpose: Establish policy and procedure regarding the transfer/discharge of residents. -When a resident is discharged of transferred the Interdisciplinary Discharge Summary must be completed. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure residents with limited range of motion received appropriate services to increase range of motion and/or prevent further decrease in range of motion when staff failed to ensure two out of two sampled residents (Residents #2 and #59) received Restorative Nursing as indicated by therapy and failed to care plan the services. Facility census was 82. The facility did not provide a policy for Restorative Nursing. Review of Facility's Dietary Resident Rights Policy dated 10/23/19 showed: -Restorative Care: The resident has the right to restorative care to attain their highest physical and mental functioning. 1. Review of Resident #2's quarterly minimum data set (MDS, a federally mandated assessment completed by facility staff), dated 1/5/21, showed: -Brief interview for mental status (BIMS) score 13. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide access or offer one resident (Resident #7), who is dependent on staff for accessing nutrition and hydration, sufficient fluid and food intake to maintain proper hydration and health. The facility census was 82. 1. Review of the facility policy for Dietary Meal Service dated 2/26/21 showed: The usual routine for total assist trays is to prepare and deliver them last. This allows nursing attendants to feed individual residents after all other trays have been delivered (unless there is extra staff to help feed residents.) The nursing department is responsible for distributing food trays to all residents in the facility that are served in their rooms or dining rooms. The nursing department is responsible for documenting resident intake by percentages. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to assure staff provided proper respiratory care when they failed to date oxygen tubing and failed to properly clean the oxygen concentrator filter which affected two of 20 sampled residents, (Resident #22 and #28). The facility census was 82. The facility did not provide a policy for dating oxygen tubing and cleaning the oxygen filters. 1. Review of Resident #22's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated, 2/5/21, showed: - Cognitive skills intact; - Independent with bed mobility, transfers, dressing, toilet use and personal hygiene; [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to assure one additionally sampled resident (Resident #45) with a diagnosis of disorders of the brain, received appropriate services. Staff failed to accurately document observed behaviors exhibited by the resident and other residents' responses to those behaviors. Staff did not develop interventions to address the resident's attention-seeking behaviors, including urinating on others beds/recliners, taking non-food items from other resident's rooms and placing them in his/her mouth, smearing feces in other's bathrooms, taking and breaking items from other residents, the level of supervision needed for the resident's health and safety, or any guidance for staff related to behavior modification for the resident. The facility's census was 82. Review of the facility's undated World of Focus Covenant Guidelines showed: [...]

Inspectors wroteBased on observation, record review, and interviews the facility failed to assure one of 20 sampled residents (Resident #35) with a diagnosis of a bipolar disorder, schizoeffective disorder and anxiety received appropriate services to aide in moving to a less restrictive environment. The facility's census was 82. 1. Review of Resident #35's MDS, dated [DATE], showed: - Cognitively able to make daily decisions; - Independent with activities of daily living; - Very important to him/her to do favorite activities, to go outside to get fresh air when weather permits. Review of the resident's care plan, dated 4/5/21, showed: - Ensure that the activities the resident is attending are compatible with physical and mental capabilities and are compatible with known interests and preferences; [...]

Inspectors wroteBased on observations and interviews, the facility failed to notify all the residents of the availability and location of the most recent survey results and did not post the most recent survey results in an accessible location to the residents without having to ask staff. This affected all residents on the secured Station One unit and on the secured Station Two unit. The facility census was 82. Review of facility policy, Resident's Rights, dated 4/29/21, showed: -Residents have the right to examine the results of the most recent survey conducted by Federal or State surveyors and any plan of correction in effect. The results must be made available in a place readily accessible to residents and post a notice of their availability. 1. Observation on 5/3/21 at 9:15 A.M., showed: [...]