Estates of Spanish Lake, the

Inspectors wroteBased on interview and record review, the facility failed to administer medications as ordered for two of three sampled residents (Resident #1 and #2). The census was 144. Review of the Administering Medication Policy, reviewed date 1/24/24, showed the following:Policy: Medications will be administered in a safe and timely manner, and as prescribed. [...]

Inspectors wroteBased on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. This had the potential to affect all residents at the facility. The census was 140. Review of the facility's Nursing Staffing Policy, reviewed 12/22/21, showed: -Policy: This facility will maintain nursing staffing ratios to ensure appropriate care is provided; -Procedure: -A copy of the Nursing Staffing Information form will be posted daily; -The facility's charge nurse and/or designee will update the number of Certified Nurse Assistants (CNAs), Nurse Assistants (NAs), Certified Medication Technicians (CMTs), Environmental Aides (EAs), Licensed Practical Nurses (LPNs), and RNs that are in the facility at the beginning of each shift throughout each 24-hour period; [...]

Inspectors wroteBased on interview and record review, the facility failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care (LTC) Ombudsman. In addition, the facility failed to maintain evidence of the submission of sent notices, including Resident #140. The census was 140. Review of Resident #140's medical record, showed: -admitted to the facility on [DATE]; -re-admitted to the facility on [DATE]. -discharged from the facility to home on 2/20/25 Review of the facility's admissions and discharge report, dated 1/1/25 to 4/11/25, showed the resident was discharged home on 2/20/25. Additionally, the discharge report showed 71 residents had been transferred or discharged during this time period. Review of the facility records, showed a fax cover sheet: -To: The Ombudsman; -Date: 4/14/25; -Phone: a local phone number; -Re: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to immediately intervene when one resident (Resident #43), who was recently hospitalized for suicidal ideation, indicated he/she wanted to commit suicide. In addition, the facility failed to address one resident's behavior when he/she became agitated and left the secured unit he/she resided on (Resident #105). The sample size was 29. The census was 140. Review of the facility's Suicidal Ideations policy, updated 1/24/25, showed: -Definition: Suicidal ideation refers to wanting to take one's own life or thinking about suicide. Should a resident have a history of or begin to show signs of suicidal ideation, the following steps must be implemented: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident received appropriate person-centered care to meet his/her highest practical psychosocial well-being when the facility failed to provide medically related social services for one resident with a known history of suicidal ideation (Resident #43). The sample size was 29. The census was 140. The Administrator was notified on 4/25/25 of the past non-compliance. The facility has hired a Social Services Director on 4/14/25. The deficiency was corrected on 4/14/25. Review of the facility's Supervision and Management of Residents with Behaviors policy, updated 1/24/25, showed: -Policy: To provide support to team members to maintain safety and security when providing care to our residents who may exhibit behaviors, while treating our residents with dignity, respect and compassion; -Protocol: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with acceptable standards of practice. The facility identified six medication carts and two medication rooms. Three of the six carts and both medication rooms were checked for medication storage. Issues were found in both medication rooms, and all three medication carts. In addition, a non-licensed staff had access to one medication room using a key located at the nurses' station. The census was 140. Review of the facility's Storage and Labeling of Medications policy, dated [DATE], showed: -Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #342) had a code status (a legal document or instructions that outlines a patient's wishes regarding medical care, particularly if they experience cardiac or respiratory arrest) and another resident's code status was accurate (Resident #32). The sample was 29. The census was 140. Review of the facility's Advanced Directive Policy & Procedure, dated [DATE], showed: -Purpose: The facility aims to support a resident's self-determination and respects each individual's right to have their choices related to healthcare planning, advanced directives, and end-of-life care preferences throughout their stay; -At the time a resident is admitted into the facility, it must be determined if a resident has existing advanced directives or wishes to establish advanced directives. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN-form CMS-10055) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for three of three sampled residents who remained in the facility upon discharge from Medicare Part A services (Residents #39, #36 and #6). The sample size was 29. The census was 140. Review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C-09-20), dated 1/9/09, showed the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a homelike environment for residents at the facility, by not ensuring ceilings and water spots in resident bathrooms were repaired during three of five days of the survey (Residents #27 and #129). In addition, the facility failed to ensure the bedroom door in one resident's room was in proper working condition and functional (Resident #69). The sample was 29. The census was 140. Review of the facility's Maintain a Safe, Clean, Comfortable, and Homelike Environment policy, reviewed 1/24/24 showed: -Policy: This facility will accommodate, to the extent possible, a personalized, homelike environment that recognizes the individuality and autonomy of each resident, while maintaining the safety of all residents and staff; -Policy Explanation and Compliance Guidelines: [...]

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 made an allegation of sexual abuse (Resident #191). The sample size was 29. The census was 140. Review of the facility's Abuse, Neglect and Exploitation policy, dated 4/8/24, showed: -Policy explanation and compliance guidelines: the abuse coordinator in the facility is the Administrator or facility appointed designee. -Report allegations or suspected abuse, neglect, or exploitation immediately to: Administrator; -State Survey and Certification agency through established procedures; -Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, sexually inappropriate interactions, or sexual assault; -Response and Reporting of abuse, neglect and exploitation: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident with a mental disorder had a DA-124 Level II evaluation (Pre-admission Screening and Resident Review (PASRR), a comprehensive assessment conducted on individuals identified by a Level I PASARR screening as potentially having a mental impairment or developmental disability) as required, for one resident investigated for PASRR requirement (Resident #106). The census was 140. Review of the facility's Pre-admission Screening and Resident Review Process, reviewed on 1/24/24, showed: -Purpose: Our facility will follow the Missouri Department of Health and Senior Services in obtaining the PASARR to determine the psychological needs they require based on their past history, allowing the facility to provide individualized care; -Process: -Prior to admission the DA 124 is completed while in the hospital; [...]

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, whose care plans did not address recent self-harming behaviors, dialysis and discharge planning (Residents #43, #121 and #120). The sample size was 29. The census was 140. Review of the facility's Care Plan and Care Plan Conference Policy, dated 8/24/24, showed: -Policy: A care plan shall be used in developing the resident's daily care routine and will be available to the team for review to ensure the best person-centered care is provided to our residents. Every quarter, an attempt will be made to schedule a care plan conference with the resident, family and/or responsible party to allow the staff to provide the best person-centered care; -Procedure; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided met acceptable professional standards of care when staff failed to transcribe one resident's new order into the computer, resulting in the resident's urine analysis (UA, urine to check for signs of disease or infection) and culture and sensitivity (C/S, a lab test to attempt to grow bacteria, viruses, or fungi. and then test which medications will effectively work to stop the infection) not being obtained (Resident #68). Staff also failed to obtain a physician order for one resident's oxygen (Resident#31). The sample was 29. The census was 140. Review of the facility's Physician Orders policy, dated 8/24/24, showed: -Purpose: The purpose of this policy is to ensure our residents receive the care prescribed by their physician; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff followed their policy for dialysis (a procedure that cleanses the blood of its impurities) when staff failed to assess/document the dialysis catheter (a catheter used for exchanging blood to and from a hemodialysis machine and a patient) or arteriovenous fistula, (AV, a surgical connection between an artery and a vein, usually in the arm, that's used for dialysis) site every shift and failed to fully complete the dialysis communication forms for two out of two residents who were receiving dialysis services (Residents #121 and #104). In addition, the facility failed to have a physician order for dialysis for one resident (Resident #104) and failed to have a contract with the dialysis companies. The sample was 29. The census was 140. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff accurately administered/documented medications, weekly skin assessments, pain and behavior monitoring, as well as blood pressure, per physician orders for two residents (Resident #31 and #62). The sample was 29. The census was 140. Review of the facility's Administering Medication policy, dated 1/24/24, showed: -Policy: Medications will be administered in a safe and timely manner, and as prescribed; -Only persons licensed or permitted by the state of Missouri to prepare, administer and document the administration of medications and/or have related functions can administer medications; -The Director of Nursing (DON) or designee will supervise and direct all nursing personnel who administer medications and/or have related functions; [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and ensure staff reported an allegation of sexual abuse, resulting in a delayed abuse investigation regarding two residents (Resident #1 and Resident #2). The sample was six. The census was 132. Review of the facility's Abuse, Neglect, and Exploitation policy, undated, showed the following: -Policy: Each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. The resident has the right to be free from mistreatment, neglect and misappropriation of property. -Resident must not be subject to abuse by anyone, including, but not limited to: Facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members, legal guardians, friends or other individuals; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure call lights were accessible to residents while in their rooms for five out of five sampled residents (Resident #5, #11, #12, #13 and #15). This had a potential to affect all residents. The census was 127. 1. Review of Resident #5's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/14/24, showed: -Cognitively intact; -Had impaired vision; -Impairment on one side of upper and lower body; -Always incontinent of bladder; -Frequently incontinent of bowel; -Dependent on staff for toileting and transfers from the bed/chair; -Required moderate assistance for rolling left and right in the bed; -Required maximal assistance to transfer from a lying to sitting position and from a sitting to lying position; -Used a wheelchair for mobility; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure pain medications were given as ordered for one of three sampled residents (Resident #14). The census was 127. Review of the facility's Administering Medication Policy, reviewed on 1/24/24, showed: -Policy: Medications will be administered in a safe and timely manner, and as prescribed; -Medications must be administered in accordance with the orders, including any required time frame; -If a medication is unavailable, the Certified Medication Technician (CMT)/Nurse will look in the First Dose Cabinet and/or central supply for over-the-counter medications, and administer the medication. If the medication is still unavailable, the CMT/Nurse will reorder the medication by either faxing or calling the request into the pharmacy; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nurses completed weekly skin assessments, weekly wound assessments and to ensure treatments were applied as ordered to pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), for one resident (Resident #5) out of three sampled residents. The facility also failed to ensure facility wound reports were accurate. This had the potential to affect all residents at risk for skin breakdown. The census was 127. Review of the National Pressure Ulcer Advisory Panel (NPUAP), prevention and treatment of pressure ulcers: Quick Reference Guide, Washington DC: National Pressure Ulcer Advisory Panel 2014 showed the following: -Assess the pressure ulcer initially and re-assess it at least weekly; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who required colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall) services received such care consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences for one resident (Resident #7) out of three sampled residents. The census was 127. Review of the facility's Administering Medication Policy, reviewed on 1/24/24, showed: -Policy: Medications will be administered in a safe and timely manner, and as prescribed; -Only persons licensed or permitted by the state of Missouri to prepare, administer and document the administration of medications and/or have related functions can administer medications; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe environment for one resident (Resident (R) 203), who resided on a secured unit, out of a total of 14 residents reviewed for accidents. The facility failed to ensure R203, who had a known history of drinking hand sanitizer and making statements indicating he/she wanted to kill himself/herself, did not have access to hand sanitizer and antimicrobial wipes. R203 reported he/she obtained and drank hand sanitizer on the night of 01/17/24 and that he/she obtained the hand sanitizer from the unit. Direct care staff were unaware of R203's previous behaviors or how to interact with R203 related to his/her behaviors. [...]

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to ensure residents were free from abuse, for seven of nine sampled residents (Resident (R) 4, R77, R84, R30, R62, R350, and R83) reviewed. Examples include: R4 struck R77 in the mouth, resulting in a cut to the inner right lip where the resident's tooth hit it, a contusion to the upper lip and a transfer to the hospital for assessment. In a second incident, R4 pulled up the shirt of one resident with impaired decision making and cognition related to intellectual disability (R84), reaching underneath R84's shirt and touching his/her chest. In a third incident, staff entered the hallway and observed R4 being punched in the face by R30 after R4 spit on R30 and threw a cup of juice on him/her. [...]

Inspectors wroteBased on observation, interview, and policy review, the facility failed to post contact information for Adult Protective Services (APS) and the Medicaid Fraud Control Unit. This had the potential to negatively affect the residents' right to contact the agencies for 118 of 118 residents who resided at the facility. The census was 118.

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to provide eight hours of Registered Nurse (RN) coverage on 31 out of 109 days reviewed for staffing. This had the potential to cause unmet health needs for 118 of 118 residents who resided at the facility.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure the required staff members (Director of Nursing (DON), Infection Preventionist (IP), and Medical Director) of the Quality Assurance (QA) Committee attended at least the quarterly QA meetings for one of four quarters. Additionally, the IP failed to attend at least quarterly QA meetings for four of four quarters. The total census was 118.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to provide or help arrange resident council meetings on a regular basis for five of five sampled residents (Resident (R) 355, R16, R85, R35, and R67) who attended the resident council meeting. The census was 118.

Inspectors wroteBased on interview and record review, the facility failed to have a system in place to ensure residents were not allowed to spend another resident's money without written authorization, causing individual resident trust fund accounts to go into a negative balance. The facility managed funds for 93 residents. A sample of 13 were chosen and the practice affected all 13 residents (Residents #102, #91, #1, #87, #3, #13, #97 #101, #103, #8, #6, #78 and #2). The census was 118. Review of the facility's Management/Protection of Resident Funds Policy, dated 4/3/19, showed the following: -A record of all transactions regarding the resident's funds shall be maintained by the facility in accordance with the generally accepted accounting principles; -The facility has a surety bond to assure the security of the president's personal fund deposited with the facility; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment on two of seven halls in ten resident rooms (Resident (R) 84, R58, R53, R44, R25, R76, R61, R78, R87 and R46). The census was 118.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to address a verbal grievance related to missing clothing for one of 32 sampled residents (Resident (R) 85) and failed to ensure five of five residents interviewed in the resident council (Resident (R) 355, R16, R85, R35, and R67) had knowledge of the facility's grievance process. The census was 118.

Inspectors wroteBased on interview and record review, the facility failed to ensure newly hired employees were screened to rule out the presence of a Federal Indicator, with the Certified Nurse Aide (CNA) Registry, for four of 10 sampled employees hired since the last survey. The facility hired at least 200 new employees since the last survey. The census was 118. Review of the facility's Abuse, Neglect and Exploitation Policy, undated, showed the following: -Policy: Each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. The resident has the right to be free from mistreatment, neglect and misappropriation of property. Residents must not be subject to abuse by anyone, including, but not limited to; [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to report allegations of resident-to-resident physical abuse, sexual abuse, and violent behaviors to the facility's Abuse Coordinator and the state survey agency for four of nine sampled residents (Resident (R) 59, R73, R84, and R4) reviewed for abuse. These failures presented a potential for continued abuse. The census was 118.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to investigate allegations of resident-to-resident physical and sexual abuse and violent behaviors for seven of nine sampled residents (Resident (R) 59, R73, R4, R77, R84, R30, and R83) reviewed for abuse. The census was 118.

Inspectors wrote2. R203's ''Face Sheet,'' dated 01/20/24, indicated R203 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia, history of TBI, major depression, history of alcohol abuse, psychoactive, abuse, PTSD, mild intellectual disabilities, epilepsy, and violent behavior. R203's quarterly MDS'' assessment with an ARD of 11/18/23 indicated a ''BIMS'' of 8 out of 15 (moderately cognitively impaired). The assessment indicated the resident experienced delusions and exhibited verbal aggression toward others frequently during the assessment reference period. R203's ''Behavior Care Plan,'' found in the EMR under the ''Care Planning'' tab and dated initiated on 10/02/23 and then most recently updated on 11/23/23 read, ''BEHAVIORS/ PSYCHOSOCIAL WELLBEING: [R203] shows aggressive behaviors by punching items, walls, and mailbox. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and services for mental and psychosocial concerns for three of 24 residents (Resident (R) 61, R78, and R209). Specifically, the facility failed to provide appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for the residents with diagnosed mental disorders and post-traumatic stress disorder. The census was 118.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident (R) 21 and R209) reviewed for self-administration of medication were safe to self-administer their own medications. R21 had an unlabeled respiratory inhaler medication at her bedside and R209 had expired topical and oral medications at his bedside. Neither resident had orders to self-administer the observed medications. The census was 118.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents and/or responsible parties were notified in a timely manner when a resident's account was within the $200.00 Social Security (SSI) limit ($5,726.00) or when the resident's account was over the SSI limit. This affected three residents reviewed who received Medicaid benefits (Residents #104, #14 and #16). The census was 118. Review of the facility's Management/Protection of Resident Funds Policy, dated 4/3/19, showed the following: [...]

Inspectors wroteBased on record review, facility policy review, and interview, the facility failed to ensure the Ombudsman was notified of hospital transfers for one resident of four residents (Resident (R) 88) reviewed for hospitalizations.

Inspectors wroteBased on record review, interview, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure one resident out of two residents (Resident (R) 58) reviewed for hospice had a significant change in status Minimum Data Set (MDS) assessment completed within 14 days of being admitted to hospice. The census was 118.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to incorporate the recommendations from the PASRR (Pre-admission and resident review) Level II determination and the PASRR evaluation report for two of 24 resident's (R) 46 and R61) plan of care. Specifically, the coordination did not occur as the PASRR Level II evaluation reports were not part of the residents' electronic medical record. The census was 118.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure that one resident of one resident reviewed for dialysis (Resident (R) 50) had communication between the facility and dialysis. In addition, the facility failed to ensure that R50's dialysis port was being assessed for signs and symptoms of infection as per facility policy. The census was 118.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure that physician follow-up to the pharmacist recommendations was implemented for two of five residents (Resident (R) 9 and 21) reviewed for unnecessary medications. The census was 118.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that the copy of the signed agreement for binding arbitration for three residents (Resident (R) 30, 78, and 354) did not include if the resident revokes the agreement the facility may terminate agreement and have resident vacate the facility within 60 days. The census was 118.

Inspectors wroteSee the deficiency cited at Event 3XlJ12. Based on interview and record review, the facility failed to keep residents free from physical abuse when Resident #1 and a staff member had a verbal altercation, which escalated into the staff member smacking a cigarette out of the resident's mouth during a smoke break. The staff member also cursed at the resident and used threatening language and posture. The staff member intentionally broke the resident's cigar in half, threw it on the ground and told the resident to pick it up. The sample was three. The census was 114. The Administrator was notified on 10/17/23, of the past non-compliance. Upon learning of the incident, facility management removed the alleged staff member from the building. The facility in-serviced staff on the abuse/neglect policy, with a special emphasis on verbal abuse on 9/22/23. The deficiency was corrected on 9/22/23. [...]

Inspectors wroteSee the deficiency cited at Event 3XlJ12. Based on interview and record review, the facility failed to follow their policy, and state and federal regulations, by not notifying the Department of Health and Senior Services (DHSS) immediately or within the required two hour time-frame, after being made aware of an allegation of employee to resident abuse for one of three residents reviewed for abuse and neglect investigations (Resident #1). The census was 114. Review of the facility's Abuse, Neglect and Exploitation policy, updated 11/30/17, showed the following: -Each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. The resident has the right to be free from mistreatment, neglect and misappropriation of property. [...]

Inspectors wroteSee the deficiency cited at 3XlJ12. Based on interview and record review, the facility failed to follow their policy to thoroughly investigate an allegation of employee to resident abuse for one of three residents reviewed for abuse and neglect investigations (Resident #1). The census was 114. Review of the facility's Abuse, Neglect and Exploitation policy, updated 11/30/17, showed the following: -Each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. The resident has the right to be free from mistreatment, neglect and misappropriation of property. Resident must not be subject to abuse by anyone, including, but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members, legal guardians, friends or other individuals; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure complete and accurate accounting of the resident trust account by not showing what the adjustments were for when reconciling the monthly trust account for 12 of 12 months reviewed. The census was 67. Review of the resident trust account reconciled bank statements, showed the following: -In 4/2020, an adjustment of $11,141.78 was made. No explanation of what the adjustment was for; -In 5/2020, an adjustment of $11,752.73 was made. No explanation of what the adjustment was for; -In 6/2020, an adjustment of negative $623.98 was made. No explanation of what the negative adjustment was for; -In 7/2020, an adjustment of negative $2448.02 was made. No explanation of what the negative adjustment was for; -In 8/2020, an adjustment of negative $512.04 was made. No explanation of what the negative adjustment was for; [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure they maintained a surety bond for the resident trust fund account in the amount of one and one half times the average monthly balance for the past 12 months. The census was 67. Record review of the resident trust account for the past 12 months from [DATE] to [DATE], showed an average monthly balance of $59,000. This would yield a required bond in the amount of $88,500 (one and one half times the average monthly balance). Review of the bond report for approved facility bonds by Department of Health and Senior Services (DHSS), showed an approved bond of $80,000 dated [DATE]. Review of the Surety Rider provided by the facility, showed an increase on [DATE] for $120,000. No where on the Rider did it show it had been submitted to DHSS for approval. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and/or implement person-centered comprehensive care plans to accurately reflect individual care needs for four residents (Residents #204, #252, #157, and #152). The sample size was 17, with an expanded sample of 13. The census was 67. 1. Review of Resident #204's medical record, showed: -Diagnoses included muscle weakness, neuropathy (nerve damage affecting the nervous system), depression, chronic kidney disease (impaired kidney function), urinary retention and hematuria (blood in urine); -A physician's order, dated 11/18/20, for Fentanyl (narcotic pain medication) 25 microgram (mcg)/hour (hr), apply to skin topically one time a day every 3 days for pain; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff obtained and document neurological assessments (neurochecks) for the 72 hours following unwitnessed falls, and to complete fall incident reports for three residents (Residents #205, #52 and #204). The facility also failed to ensure staff documented the administration of resident medications and accu-checks (blood sugar readings) according to physician's orders (Residents #203, #251, #58, #157 and #53). The sample was 17. The census was 67. 1. Review of Resident #205's face sheet, showed diagnoses included seizure disorder, convulsions, intellectual disability, depression, abnormalities of gait and mobility, and generalized muscle weakness. Review of the resident's medical record, showed: -Fall risk evaluation, dated 6/26/20, identified the resident at risk of falls; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received restorative therapy (RT) as ordered. The facility identified eight residents that should receive RT services. Of those eight, seven were sampled and one of those seven had a decline in their physical abilities. In addition, the facility was unable to provide documentation showing any of the seven resident's received RT services as ordered. (Residents #201, #152, #157, #52, #54, #55, and #253). The census was 67. 1. Review of Resident #201's medical record, showed diagnoses included dementia, seizures, unsteadiness on feet, fracture around prosthetic right hip, fracture at right femur (bone located in the thigh of the upper leg) and history of falling, unspecified abnormalities of gait and mobility. Review of the resident's care plan, initiated on 10/20/20, last revised on 4/6/21, showed: -Problem: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure other interventions were tried prior to the use of side rails, properly assess residents for the use of side rails, and update resident care plans regarding the use of side rails. The facility identified 10 residents who utilized side rails in the facility. Five of the residents who utilized side rails were sampled and problems were identified with all five (Resident #157, #152, #204, #103 and #105). The sample size was 17. The census was 67. 1. Review of Resident #157's medical record, showed diagnoses included osteoarthritis of the knee, obesity, unspecified abnormalities of gait and mobility and generalized muscle weakness. Review of the resident's care plan, last updated on 9/22/20 and in use during the survey, reviewed on 4/5/21, showed: -Problem: [...]

Inspectors wroteBased on interview and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation. The controlled substance shift change count check sheets were missing documentation for three of the six facility medication carts. The census was 67. 1. Review on 4/1/21 at 8:27 A.M., of the facility's first floor Controlled Substance Shift Change Check Sheet, dated March 2021, completed by the nurse, showed the following: -60 of 93 shifts, staff failed to count the number of narcotic cards; -67 of 93 shifts, staff failed to document initials to indicate the count was correct. During an interview on 4/1/21 at 8:31 A.M., Nurse G said each nurse is to count each narcotic cards and document the amount of cards on the Controlled Substance Shift Change Sheet. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure its medication error rates were not 5% or higher. Out of 33 opportunities for error, four errors occurred, resulting in a 12.12% medication error rate (Residents #154, #253 and #255). The census was 67. 1. Review of Resident #154's physician's order sheets (POS), dated 4/5/21, showed the following: -An order, dated 8/19/20, for Incruse Ellipta 62.5 mcg (a prescription medication used to treat chronic obstructive pulmonary disease (COPD, a group of lung disease that block airflow and make it difficult to breathe and emphysema (lung condition that causes shortness of breath)), inhaler; Give one puff orally one time a day for COPD; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff completed routine inspections of bed frames, mattresses, and bed rails to identify areas of possible entrapment with side rail usage to reduce the risks of accidents. The facility identified 10 residents with side rails in use. Five of the residents were sampled and problems were identified with all five (Residents #157, #152, #204, #103 and #105). The sample size was 17. The census was 67. 1. Review of Resident #157's medical record, showed diagnoses included osteoarthritis of the knee, obesity, unspecified abnormalities of gait and mobility and generalized muscle weakness. Review of the resident's care plan, last updated on 9/22/20 and in use during the survey, showed: -Problem: Has an ADL (activities of daily living) self-care performance deficit related to obesity; -Goal: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for one of 17 sampled residents (Resident #253). The facility census was 67. Review of the facility's resident rights policy, dated 12/1/19, showed the following: -Policy: To provide quality healthcare through communications, respect and sensitivity between the residents and those who provide them care. The facility strives to promote the exercise of rights for each resident, even if he or she is determined incompetent, should be able to assert these rights based on his or her degree of capability; -All of the facility residents have the following rights: Dignity, privacy and respect; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary services to maintain good grooming and personal hygiene for four residents who required staff assistance for performance of activities of daily living (Residents #204, #163, #152, and #103). The sample size was 17. The census was 67. 1. Review of Resident #204's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/27/21, showed: -Rejection of care not exhibited; -Limited assistance of one person physical assist required for dressing and personal hygiene; -Diagnoses included depression and generalized muscle weakness. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide an ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, for three of three residents sampled for activities (Residents #252, #207, and #208). The census was 67. 1. Review of Resident #252's medical record, showed diagnoses included depression. Review of the resident's care plan, undated and in use at the time of survey, showed: -Problem: The resident has depression related to: staff left blank; -Goal: The resident will exhibit indicators of depression, anxiety, or sad mood less than daily by review date; -Approaches: staff left blank; -No documentation of the resident's activity preferences. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to notify the physician in a timely manner of a change in condition for one of two closed record sampled residents (Resident #102). The census was 67. Review of Resident #102's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/27/19, showed: -Diagnoses of Multiple Sclerosis, high blood pressure, diabetes and dementia; -Short/long term memory problems; -Required extensive staff assistance for eating; -Required total staff assistance for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing; -Incontinent of bowel and bladder. Review of the resident's progress notes, showed: -3/22/2020 at 7:29 A.M.: Abdomen girth is very distended with very faint bowel sounds noted. Denies complaints of pain when touched. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to identify two unstageable pressure ulcers on a resident's sole of the right foot and the heel of the right foot. In addition, nurse's failed to complete the resident's weekly skin assessments routinely and a certified nursing assistant (CNA) failed to remove the resident's socks during bathing to check for skin breakdown. The resident was not one of three residents the facility identified with a known pressure ulcer (Resident #55). The census was 67. Review of the facility Pressure Ulcer Risk Assessment policy, revised 4/20, showed: Policy: -It is the policy of this facility to perform a pressure ulcer risk assessment as part of our systematic approach for pressure ulcer prevention. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement interventions, including adequate supervision, consistent with a resident's needs, goals, care plan and current professional standards of practice in order to eliminate the risk and/or reduce the risk of an accident. The facility also failed to monitor the effectiveness of the interventions and modify the care plan as necessary, in accordance with current professional standards of practice for two of 17 sampled residents (Residents #201 and #254). The census was 67. Review of the facility's falls and fall risk management policy, last updated on 12/10/18, showed the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional standards for two of six medication carts. The census was 67. 1. Observation on 4/1/21 at 8:28 A.M., of the second floor medication cart for A hall, showed the following: -An uncovered plastic medication cup filled with small pills. It had a handwritten label of Melatonin (a hormone primarily released by the pineal gland at night, and has long been associated with control of the sleep-wake cycle) 5 milligrams (mg) on the side of the cup; -One open vial of artificial eye drops, dated and labeled only with a resident's first name; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff who provided perineal care (cleansing between the legs and buttocks area) to dependent residents, followed acceptable hand hygiene infection control practices by failing to change gloves before applying barrier cream for one of two residents observed receiving personal care. (Resident #204). In addition, staff failed to clean the glucometer (machine used to check blood sugar levels) before and after use for Resident #252. The glucometer was used for multiple residents. The census was 67. 1. Review of the facility's Perineal Policy, updated on 12/10/15, showed the following: -Policy: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide written notice of facility-initiated transfers to the Office of the State Long Term Care Ombudsman's Office for 27 of 27 residents transferred from 1/1/21 thru 4/1/21. The census was 67. On 3/6/21, the Ombudsman stated the State Long Term Care Ombudsman's office had not received notice of facility-initiated transfers from the facility for several months. During an interview on 4/6/21 at 9:44 A.M., the administrator said it is the responsibility of the social service director (SSD) to notify the Ombudsman's Office of facility-initiated transfers at the end of every month. Her last SSD quit a couple of months ago. She looked through the former SSD's e-mails. Of the 27 residents that had facility-initiated transfers since 1/1/21 thru 4/1/21, she could not find documentation that the Ombudsman's Office had been notified. [...]