Ellisville Rehabilitation and Nursing

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from physical abuse when one staff member, Certified Nursing Assistant (CNA) A struck two residents. On 06/28/26 at approximately 2:50 A.M., CNA A was observed by Licensed Practical Nurse (LPN) B and CNA D using excessive force for one resident (Resident #2) while boosting him/her up in bed which caused Resident #2 to hit his/her head on the backboard. CNA A was also observed striking the resident on the lower back with a closed fist. Between 4:00 A.M. to 4:30 A.M., LPN B assessed CNA A and instructed him/her to leave the facility, due to concerns of intoxication. CNA A did not leave the facility as instructed. CNA A pleaded with LPN B to stay and was allowed to continue with his/her assignment. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff immediately reported an incident of abuse involving Certified Nursing Assistant (CNA) A and one resident (Resident #2) to the Administrator, in accordance with the facility policy. This resulted in the facility's failure to report the allegation of abuse to the State Survey Agency within the required timeframe of two hours, and CNA A remained in the facility and physically abused a different resident (Resident #1) during the same shift. This deficient practice had the potential to affect all residents receiving care from CNA A. The census was 129. The administrator was notified on 07/08/26 of the past non-compliance which occurred on 06/28/26. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure physician-ordered treatment was provided for one resident (Resident #3) by failing to obtain and administer the ordered Gentamicin (antibiotic) catheter (a thin, flexible tube inserted into the body to drain fluids, deliver medications, or perform diagnostic tests) irrigation solution in a timely manner. Facility staff failed to provide the ordered treatment for four out of fifteen days in [DATE]. On [DATE], the resident requested removal and replacement of the urinary catheter because the ordered antibiotic irrigation had not been administered. During catheter replacement, there was no urine return, and bleeding occurred that staff was unable to control. The resident required transfer to the hospital for evaluation and catheter replacement. [...]

Inspectors wroteBased on interview and record review, the facility failed to appropriately respond to one resident's (Resident #35) change of condition and/or conduct and document a thorough assessment and contact the resident's physician. The resident began vomiting on 02/25/26, continued to vomit through 03/01/26 when staff called 911 to send him/her to the hospital. Staff documented the nurse practitioner (NP) assessed the resident on 2/26/26. The order for ondansetron (Zofran, anti-nausea medication) was sent on 2/27/26. Staff administered the medication on 2/27/26 at 1:53 P.M. The resident continued to vomit after the administration of the medication. On 2/28/26, staff said the vomit started to darken in color. Staff did not document notification to the physician when the vomiting continued or darkened in color until 3/1/26. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure services provided met acceptable professional standards of care when staff failed to administer and document morning and afternoon medications as order by the physician for seven residents (Resident #8, Resident #7, Resident #11, Resident #9, Resident #12, Resident #2 and Resident #6 and Resident #10). Additionally, the facility failed to refill Hydrocodone (prescription opioid used for moderate to severe pain) 5-325 milligrams (mg) for one resident (Resident #4) who had severe pain in a timely manner. The resident did not receive his/her hydrocodone for two days. The sample was 18. The census was 109. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain food at a palatable, safe, and appetizing temperature during meal service. This deficiency affected five of 11 sampled residents (Residents #19, #24, #25, #28, and #21). The census was 126. Review of the facility's On Tray Dietary Policies and Procedures, not dated, showed:-Food temperatures are maintained during serving times;-Food and beverage temperatures should be taken and logged upon being cooked and again prior to meal service;-Food temperatures should be within the required temperatures per state and federal guidelines when cooked and served. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide residents with alternate food choices and preferences listed on the Always Available menu (Residents #4 and #25). In addition, the facility failed to serve foods listed on meal tickets for three of 11 sampled residents (Resident #22, #19, and #24). The census was 126. Review of the dietary Always Available menu on 03/02/16, showed items included hamburger/cheeseburger, grilled cheese, cold cut sandwiches, chef or garden salad, cold cereal, hot dogs, and peanut butter and jelly sandwiches. 1. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 11/30/25, showed: -admitted on [DATE];-Cognitively intact. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents right to personal privacy and confidentiality when Certified Nursing Assistant (CNA) A provided peri-care (incontinence care) to a resident (Resident #1) during a video call with CNA B and Scheduler H. CNA B was at home and two children were on camera with him/her. The resident's genitals and buttocks were exposed. Additionally, CNA B took pictures of a resident (Resident #2) while he/she slept and shared it to a group chat with staff and non-staff members. The sample was 18. The census was 109. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to promptly document and investigate a physical relationship between two cognitively impaired residents (Resident #33 and #39) after it was reported staff observed them together in one of their rooms, with one of the residents partially unclothed. The facility also failed to follow their policy, notify the residents' physician and immediately update the care plan with interventions to protect the residents and their rights. The sample was 15. The census was 130. Review of the facility's Abuse, Neglect, and Exploitation policy, dated 2022, showed:-Policy: It is the policy of the facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property; [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct a thorough and immediate investigation of an injury of unknown source after a facility Certified Nurse Assistant (CNA) discovered a resident (Resident #20), with a bruise on his/her neck fold and under his/her left eye. The resident said he/she remembered staff helping him/her off the floor. He/She did not remember falling. The sample was 11. The census was 126. Review of the facility's Abuse Policy, not dated, showed the following:-It is the policy of the facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures which prohibit and prevent abuse and neglect;-Alleged violation is defined as a situation or occurrence observed or reported by staff, resident, relative, visitor or others, but has not yet been investigated. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident care plans were updated and accurate to reflect resident needs. This failure affected three residents (Residents #22, #23, and #24) whose care plans did not address increased need for eating assistance, increased depression, safety concerns, increased confusion, wandering behavior, and recent fall interventions. The sample size was 11. The census was 126. Review of the facility's Comprehensive Care Plans policy dated 9/24, showed:-Policy: [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure one resident with an indwelling urinary catheter (a sterile tube inserted into the bladder through the urinary tract to drain urine) was provided catheter care and antibiotic flushes as ordered for one of three residents sampled for catheter care (Resident #19). The resident suffered from several urinary infections in the prior months leading to hospitalizations and this failure increased the risk of another infection. The census was 126. Review of the facility's Catheter Care policy revised 5/25, showed:-Policy: It is the policy of the facility to ensure residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use:-Policy Explanation: --Catheter care will be performed every shift and as needed by nursing personnel; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer and ensure the resident consumed nutritional supplements for one resident who was identified with significant weight loss and wounds (Resident #19). This failure could result in continued weight loss and/or deterioration of wounds. The sample was 11. The census was 126. Review of the facility's Nutrition/Hydration Management policy, revised 12/25, showed:-Policy: Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;-Compliance guidelines: Weight can be a useful indicator of nutritional status. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services when a nurse dispensed and signed out narcotics and allowed Certified Medication Technician (CMT) J to administer them to two residents (Resident #19 and #22). Additionally, a resident (Resident #17) refused his/her medication, and the nurse disposed of the medications in the resident's trash can. The sample was 11. The census was 126. Review of the facility's Controlled Substance Administration and Accountability policy, dated 9/24, showed:-Policy: It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place to prevent loss, diversion or accidental exposure.-Policy Explanation and Compliance Guidelines: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident's right to be free from physical abuse was not violated when another resident hit the resident in the face, resulting in the resident's face being scratched (Residents #4 and #5). The sample was five. The census was 113. Review of the facility's Abuse, Neglect and Exploitation Policy, dated 4/28/25, showed the following: -Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property; -Definition: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from unnecessary physical restraints when staff held one resident's wrist down while providing personal care (Resident #503). The staff did not follow facility policy or the resident's care plan when the resident was resistive to care. After the resident refused care, the staff continued to provide care while holding the resident down, instead of allowing the resident to calm down and self-soothe, as the care plan instructed. During the forced care, the resident's behaviors remained escalated when he/she swung, kicked, and bit the staff. A skin assessment on the day of the incident showed a skin tear to the resident's chin and bruising on both hands. The sample was 23. The census was 111. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to follow its policy to have an Administrator who planned, directed and monitored compliance with State and Federal government regulatory agencies by not having an active Administrator on-site on a full time basis. The facility census was 123. Review of the facility's (undated) job description for the Administrator, showed: -Job Title: Administrator; -Reports To: Chief Operating Officer; -Status: Exempt; -Positions Summary: -Provides leadership, oversight and administration to all long-term care operations. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide basic life support including cardiopulmonary resuscitation (CPR, a lifesaving technique that's used in emergencies in which someone's breathing and/or heartbeat has stopped) after Resident #1 had a rapid change in condition and coded. Registered Nurse (RN) F began CPR when he/she was unable to locate the resident's code status (initiate CPR or do not initiate CPR). RN F did not call for additional staff assistance over the facility intercom system, did not provide rescue breaths during CPR, and did not use the automated external defibrillator (AED, a portable device that can be used to treat a person whose heart has suddenly stopped working) located at the nurse's station. RN F did not continue CPR until emergency medical services (EMS) arrived at the resident's bedside. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their Abuse Prevention and Prohibition Program policy by failing to thoroughly investigate Resident #4's allegation that Certified Nurse Assistant (CNA) BB provided rough care while cleaning him/her up causing a hematoma (a localized collection of blood outside of blood vessels that forms due to injury or trauma) on his/her left inner calf. The resident resided on the fourth floor. The CNA's normal assignment was on the third floor. Review of the facility investigation showed three residents who resided on the fourth floor were interviewed, including Resident #4. No residents from the third floor were interviewed and no staff from either floor were interviewed including staff that worked when the alleged incident occurred. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the State Survey Agency (Department of Health and Senior Services-DHSS) no later than two hours after one resident (Resident #4) alleged Certified Nurse Aide (CNA) BB was rough while providing personal care, causing a hematoma (a localized collection of blood outside of blood vessels that forms due to injury or trauma) on his/her left inner calf. The sample size was 14. The census was 135. Review of the facility Abuse policy dated 11/22/23, showed: -Definitions: -Abuse is defined as the willful infliction of injury, intimidation, or punishment with resulting physical harm, pain, or mental anguish; -Mistreatment is defined as inappropriate treatment or exploitation of a resident; -Policy: [...]

Inspectors wroteBased on interview and record review, the facility staff failed to appropriately respond to a resident's (Resident #1's) change of condition, failed to conduct a thorough, documented assessment, and failed to contact the resident's physician, regarding the resident's change of condition, which began on 2/20/25. Staff failed to assess the resident who was not eating, stared blankly and could not keep his/her head up. The resident became unresponsive and was sent to the hospital with diagnoses of pneumonia (a lung infection, often caused by bacteria, viruses, or fungi, that inflames the air sacs (alveoli) and can lead to fluid or pus buildup, causing symptoms like cough, fever, and difficulty breathing), respiratory failure, and sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection, leading to widespread inflammation and organ damage). [...]

Inspectors wroteBased on interview and record review, facility staff failed to keep a resident free from hazards and provide the necessary monitoring and supervision for a resident when outside of the facility. The facility failed to follow their Elopement/Missing Person policy after one resident (Resident #1) left the facility's premises without the staff's knowledge of the resident's whereabouts or expected time of arrival back to the facility. The facility also failed to assess the risk of leaving the facility without notification to staff due to a possible substance abuse disorder when staff found four shot bottles (miniature bottles of 50 milliliters (ml) alcohol) in the resident's bedroom. The sample size was three. The census was 138. Review of the facility's Elopement/Missing Person policy, dated 11/24, showed: -Policy: [...]

Inspectors wroteBased on interview and record review, the facility staff failed to appropriately respond to a resident's (Resident #351) change of condition, failed to conduct a thorough, documented assessment, and failed to contact the resident's physician, regarding the resident's change of condition, which began on [DATE]. The resident expired in the facility on [DATE]. The sample was 23. The facility census was 134. The Administrator was notified on [DATE] at 11:45 A.M., 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, undated Change of Condition Notification Policy and Procedure, showed: -Definitions: Significant change in the resident's condition: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pain management for Resident #524, who complained of pain when staff provided care upon waking, again when assessed by therapy at breakfast and also when put to bed after dinner. The resident was administered no pain medication for 19 hours until he/she was transferred to the hospital after an x-ray showed the resident had a fractured hip. The facility staff also failed to provide as needed (PRN) pain medication to Resident #516 who suffered from chronic pain for four hours. The facility also failed to ensure Resident #507's Lidocaine patch (a topical pain reliever) was ordered timely and administered as ordered. [...]

Inspectors wroteBased on interview and record review, the facility failed to assess and document findings for 72 hours, in accordance with the facility's policy after one sampled resident experienced an unwitnessed fall (Resident #99). In addition, the facility failed to update the resident's care plan. The sample size was 23. The census was 115. Review of the facility's Fall Protocols Policy, dated 10/22/23, showed: -Policy: The nursing staff, in conjunction with the interdisciplinary team will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. The facility will maintain the environment in a manner to promote safety; -Actual Fall: If a resident experiences a fall, the resident will be assessed for potential injury and a change in condition; [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain documentation of a system that assured complete accounting of resident personal funds, and the facility failed to ensure access to resident personal funds was transferred to the facility's new management company upon a change in ownership. The facility also failed to ensure that monies held in the resident trust fund account was reconciled each month. The facility also failed to ensure quarterly statements were distributed to residents and/or their responsible party. This deficient practice affected all residents whose funds were handled by the facility. The census was 115. Review of the facility's undated Resident Personal Funds - Accounting and Management policy, showed: -Hold, safeguard, manage, and account for: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was served at a safe and appetizing temperature for two of two observed meal services. This deficient practice affected all residents who ate meals at the facility, including members of the Resident Council who voiced complaints in the monthly resident council meetings and Residents #1 and #92. The census was 134. Review of the facility's Monitoring Food Temperatures for Meal Service policy, dated 2020, showed: -Guideline: Food temperatures will be monitored to prevent foodborne illness and ensure foods are served at palatable temperatures; -Procedure: Proper procedures are followed to ensure that food temperatures are accurately and safely obtained according to safe handling practices. These procedures include the following steps; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff adequately supervised residents during medication administration and/or assessed residents to self-administer medications and/or keep medications at their bedside (Residents #54, #61, #17, #81, #29, #88 and #92). The sample was 23. The census was 115. Review of the facility's undated Medication Administration Policy, showed: -Policy: the facility is committed to establishing and maintaining processes that promote safe medication administration; -Medications will be administered by the person licensed or permitted by the state to prepare, administer, and document the administration of medications; -The Director of Nursing (DON) services will supervise and direct all nursing personnel who administer medications and/or have related functions; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to investigate Resident #524's injury of unknown origin. An x-ray confirmed a right femur/hip fracture on 3/15/25 and the resident was sent to a hospital for evaluation and treatment. In addition, the facility failed to interview all staff with knowledge of Resident #504's fall from bed, which caused a laceration above the resident's right eye, and failed to interview residents and staff after one Certified Nursing Assistant (CNA) allegedly cursed at Resident #507, and failed to investigate Resident #502's left upper and back arm bruises. This deficient practice affected four out of 30 sampled residents. The census was 114. Review of the facility's Abuse policy and procedure dated 11/22/23, showed: Definitions: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all residents were treated in a manner to maintain dignity when one resident continued to have a certain staff assigned to them despite their request for a different staff member (Resident #84). In addition, staff used their personal cell phones in resident care areas and while providing care to the residents. The sample was 23. The census was 115. Review of the facility's Resident Rights policy, dated 11/22/24, showed: -Policy: The facility recognizes and respects that each resident has the right to exercise his or her rights as a resident of the facility and as citizen or resident of the United States. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents or the resident's responsible party (RP) were invited to participate in all aspects of person-centered care planning for one resident who was not notified after his/her insurance was changed by the facility (Resident #67). The sample was 23. The census was 115. Review of the facility's Resident Rights policy, dated 11/22/24, showed: -The facility recognizes and respects that each resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. Exercising rights mean that residents have autonomy and choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to the facility's rules, as long as those rules do not violate a regulatory requirement. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify third party (TPL) within 30 days when a resident expired. This affected two residents who expired (Residents #171 and #172). The census was 115. Review of the facility's undated Resident Personal Funds - Accounting and Management policy, showed: -Hold, safeguard, manage, and account for: Means that the facility must act as fiduciary of the resident's funds and report at least quarterly on the status of these funds in a clear and understandable manner. Managing the resident's financial affairs includes money that an individual gives to the facility for the sake of providing a resident with a non-covered service. In these instances, the facility will provide a receipt to the gift giver and retain a copy; -Procedures/Requirements: The resident may manage his or his own personal funds; [...]

Inspectors wroteBased on interview and record review, the facility failed to notify hospice services after a resident fell and was transferred to the emergency room. The facility also failed to notify the resident's responsible party prior to transferring the resident to the emergency room (Resident #222). The sample size was 23. The census was 115. Review of the facility's undated Hospice Services Policy and Procedure, showed: -Definitions: Hospice Care means a comprehensive set of services identified and coordinated by an interdisciplinary group to provide for the physical, psychosocial, spiritual and emotional needs of a terminally ill patient and/or family members, as delineated in a specific patient plan of care; -Terminally Ill means the individual has a medical prognosis that his or her life expectancy is six months or less if the illness runs its normal course; -Policy: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #507) was free from verbal abuse and treated with respect and dignity, when a Certified Nurse Aide (CNA) used profanity at the resident and to not identity him/herself after being asked. In addition, the CNA continued to worked at the facility and was assigned to the resident. The sample was 30. The census was 114. Review of the facility's Resident's Rights policy, dated 11/22/24, showed the resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the resident. The resident has the right to exercise his or her rights as a resident of the facility and as citizen or resident of the United States. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized care plans to address the specific needs of the residents (Residents #87 and #99). The sample was 23. The census was 115. Review of the facility's Resident Centered Care Plan Policy, dated 7/17/23, showed: -Policy: A person-centered comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs shall be developed for each resident. To the extent practicable, the resident/resident representative will be provided with opportunities to participate in the care planning process. -A comprehensive care plan for each resident will be developed within seven (7) days of completion of the resident's comprehensive Minimum Data Set (MDS) assessment; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide services and/or treatment to increase or prevent reduction of range of motion. The facility failed to develop a measurable, goal oriented restorative nursing program, and/or exercise program, to ensure resident's requiring physical assistance were assisted by staff to maintain or improve their physical abilities, per facility policy. The facility provided a list of 16 current residents who had been discharged from skilled therapy services (Physical therapy (PT), Occupational Therapy (OT) or Speech Therapy (ST)) within the past 90 days. Of those 16, three were identified who would benefit from services to prevent reduction of range of motion (Residents #527, #525, and #526). The census was 114. Review of the facility's undated Restorative Nursing Services Policy and Procedure, showed: -Definitions: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow acceptable infection control standards by not implementing Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) that employs targeted gown and glove use during high contact resident care activities) as recommended by the Centers for Disease Control and Prevention (CDC) and required by the Centers for Medicare and Medicaid Services (CMS) for residents with wounds requiring treatments (Resident #10). [...]

Inspectors wroteBased on observations, record review and interviews the facility failed to store, prepare, distribute, and serve food under sanitary conditions. Specifically, the facility: failed to label food items in dry storage, the chef cooler, the freezer, the produce walk in, snack food and drink walk in refrigerator, and deli/sandwich preparation refrigerator; failed to clean the kitchen floors, preparation table shelves and drawers, stove, ovens, air fryer, red colored hotbox, the tilt skillet, and the steamer/convection oven; and failed to ensure cutting boards did not have cut marks (scarring) from the knives. The facility census was 106.

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident had a choice of code status documented in the medical record (Resident #78). In addition, the facility failed to ensure four out of 23 sampled residents' code status' were reviewed annually (Residents #56, #103, #42 and #84). The census was 110. Review of the facility Life Sustaining Treatment policy, revised [DATE], showed: -Practice: Upon admission the resident will be made aware of his/her right to make informed decisions through the information contained in the resident handbook and other materials furnished by Social Services and/or the business office; -Should a resident have an advance directive, it will be filed in the front of the resident's medical record; [...]

Inspectors wroteBased on 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 discharge status for two out of three closed records reviewed (Residents #110 and #109). The census was 110. 1. Review of Resident #110's discharge MDS, dated [DATE], showed: -Type of discharge (planned or unplanned): Unplanned; -Discharge status: To community; -discharge date : [DATE]. Review of the resident's progress notes, dated 11/6/19, showed the resident transferred to the hospital on this date and time. Family refused to wait on discharge papers from this nurse and stated the resident still had his/her personal items in the room. 2. Review of Resident #109's discharge MDS, dated [DATE] showed: -discharge date : [DATE]; -Discharge status: Acute hospital. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident admitted into a Medicaid certified bed, regardless of payment source, had the DA-124c level I screen (used to evaluate for the presence of psychiatric disorders and intellectual disabilities) completed prior to admission into the Medicaid certified bed, for one of five residents investigated for preadmission screening and resident review (PASARR) (Resident #88). The sample was 23. The census was 110. Review of Resident #88's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/8/19, showed: -Section A0410: Unit certification or licensure designation: Unit is Medicare and/or Medicaid certified; -Section A1500: PASARR: No -Section A1510: Level II PASARR conditions: -A 1510: A serious mental illness: blank; -A 1510: B intellectual disability: blank; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed ensure the services provided or arranged by the facility met professional standards of quality, by failing to follow physician orders for a fall mat for one resident (Resident #87) who had a history of falling. The sample was 23. The census was 110. Review of Resident #87's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/5/19, showed: -Moderately impaired cognition; -Extensive assistance of staff required for bed mobility, dressing, grooming and bathing; -Total assist of staff required for transfers; -Used a wheelchair; -Frequently incontinent of urine and occasionally incontinent of bowel; -Diagnoses included heart failure, high blood pressure, diabetes, high cholesterol and depression. Review of the resident's medical record, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain proper placement of an indwelling urinary catheter (a tube inserted into the bladder for purpose of continual urine drainage) and failed to obtain physician orders for the catheter. The facility identified seven residents as having indwelling urinary catheters. Of those seven, five were chosen for the sample. Of those five, problems were found with two residents (Residents #106 and #78). The sample was 23. The census was 110. Review of the facility's catheter care policy, revised April 2019, showed: -Policy: Catheter care is performed each shift and as needed to keep catheter and perineal area clean; -The urinary drainage bag and tubing is not changed unless absolutely necessary and it is of utmost importance to maintain strict aseptic (free from contamination) technique; -Catheter Care Practice: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents are free of significant medication errors for one resident (Resident #103) when the facility staff administered a medication then immediately initiated a tube feeding (nutrition administered per a gastric tube, g-tube. A tube placed through the abdomen into the stomach), for a medication that should not be given with food. The census was 110. Review of Resident #103's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/13/19, showed: -The resident is rarely or never understood; -The resident required total assistance of staff for grooming, dressing, bathing, hygiene, transfers and eating; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles, for two of two medication carts reviewed. The census was 110. Review of the facility's pharmacy services, storage and expiration dating of medications, biologicals, syringes and needles policy, updated 10/2016, showed: -Facility should ensure that medications and biologicals that have an expired date on the label, have been retained longer than recommended by manufacturer or supplier guidelines or have been contaminated or deteriorated are stored separate from other medications until destroyed or returned to the pharmacy or supplier; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the hand hygiene policy during personal care for one of three residents observed during personal care (Resident #17). The census was 110. Review of the facility's hand hygiene policy, dated 10/18, showed: -Purpose: To establish guidelines for proper hand hygiene practices for infection control; -Responsibility: It is the responsibility of all employees to follow this policy regarding hand hygiene for infection control; -Policy: Hand hygiene will be maintained at all times. Hands will be washed with soap and water when they are visibility soiled or contaminated with blood or other body fluids; -Practice: Recommended times for handwashing with soap and water, when hands are visibly soiled or after contact with blood or body fluids. Review of Resident #17's care plan, revised on 4/16/19, showed: -Problems: [...]

Inspectors wroteBased on observation and interview, the facility failed to post the required information for the daily nursing staffing information by not posting the name of the facility and daily census for five of five days of observation. The census was 110. Observation on 1/6/20 at 1:00 P.M., 1/7/20 at 8:45 A.M., 1/8/20 at 7:26 A.M. and 1:45 P.M., 1/9/20 at 2:00 P.M., and 1/10/20 at 7:45 A.M., showed the name of the facility and the daily census not listed on the nursing staffing information. During an interview on 1/10/20 at 1:42 P.M., the Administrator said he did notice that the name of the facility was not on the nursing staff information. He would expect the posting to include the name of the facility and the resident census.