Fieser Nursing Center

Inspectors wroteBased on interview and record review, the facility failed to electronically submit to the Centers for Medicare and Medicaid Services (CMS) complete and accurate direct care staffing information no less frequently than quarterly, for three quarters preceding the annual survey. The census was 38. Review of the fiscal years Payroll Based Journal (PBJ) staffing report, showed the facility triggered for failing to submit data for:-Fiscal year quarter 1, 2025 (October 1 to December 31);-Fiscal year quarter 2, 2025 (January 1 to March 31);-Fiscal year quarter 3, 2025 (April 1 through June 30). During an interview on 9/25/25 at 10:18 A.M., the Administrator said she has not been able to log in to the account to submit the PBJ. The account kept saying it was the incorrect password. The help desk would send a new password, but she still was not able to get in. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure their facility assessment was reviewed and updated as necessary and at least annually. The census was 38. Review of the facility's Facility Assessment policy, revised 9/18/17, showed:-Requirement: Nursing facilities will conduct, document and annually review a facility-wide assessment, which includes both their resident population and the resources the facility needs to care for their residents;-Purpose: The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure quality assessment and assurance (QAA) meetings consisted of the required committee members when the Medical Director failed to attend the facility's QAA meetings. The census was 38. Review of the facility's Quality Assurance Performance Improvement (QAPI) Program policy, dated 1/7/25, showed:-Guiding Values or Principles: [...]

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) and use good infection control practices while providing wound treatments on two residents (Resident #15 and Resident #5). The sample was 12. The census was 38. Review of the facility's Clean Dressing Change policy, dated 1/16/25, showed:-Intent: It is the policy of the facility to change dressing in accordance with state and federal regulations. -Procedure: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Certified Nursing Assistants (CNA) received a minimum of 12 hours of ongoing education annually for three out of three sampled CNAs (CNA D, CNA C and Certified Medication Technician (CMT) E). The census was 38. Review of the facility's Required In-service Training for Nurse Aides, dated, 1/16/25, showed-Intent: It is the policy of the facility to provide a staff education plan in accordance with state and federal regulations;-Procedure: Required in-service training for nurse aides will: -Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year; -Include dementia management training and resident abused prevention training; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were assessed to self-administer medications and physician orders were maintained for self-administration of medication for one resident observed with medications left at bedside (Resident #41). The sample was 12. The census was 38. Review of Resident #41's medical record, showed diagnoses included asthma-chronic obstructive pulmonary disease (COPD, lung disease) overlap syndrome (symptoms of both asthma and COPD) and heart failure. Review of the resident's physician order summary (POS), showed:-An order, dated 8/16/25, for albuterol sulfate hydrofluoroalkane (HFA) aerosol inhaler (medication used to treat asthma); 90 microgram (mcg)/actuation (release of a single dose); [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure reports with respect to surveys, certifications and complaint investigations conducted during the preceding three years were available for review by residents, family members and legal representatives of residents. The census was 38. Review of the facility's list of resident rights, undated, showed the right to be fully informed of state survey reports. Observations on four out of four days of survey, showed no reports with respect to surveys, certifications and complaints available for review. There was no notice posted regarding availability of survey results. During a group interview on 9/29/25 at 1:30 P.M., four out of four residents, whom the facility identified as alert and oriented, said they did not know they had the right to review survey results. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents are free from chemical restraints imposed for purposes of discipline or convenience by not limiting one resident's as needed (PRN) psychotropic (a medication used to treat mental and emotional disorders) to 14 days (Resident #40). The sample was 12. The census was 38. Review of the facility's Pharmacy Services- Drug Regimen Free from Unnecessary Drugs policy, dated 1/16/25, showed:-Intent: The intent of this policy is each resident's entire drug medication regimen is managed and to promote or maintain the residents highest practicable mental, physical, and psychosocial well-being; The facility implements PRN orders for psychotropic medications are used when the medication is necessary and PRN use is limited;-Procedure: PRN orders for psychotropic drugs are limited to 14 days. [...]

Inspectors wroteBased on interview and record review, the facility failed to document a discharge summary that included a recapitulation of stay, final summary of resident's status at the time of discharge, and reconciliation of medications for one resident sampled for discharges (Resident #38). The sample was 12. The census was 38. Review of the facility's Discharge Summary policy, undated, showed:-Intent: It is the policy of the facility to assure that a discharge summary is completed in accordance to State and Federal requirements;-Procedure:--When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following:-a. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a Level I Preadmission Screening and Resident Review (PASARR, a federally required screening for all applicants to a Medicaid-certified nursing facility to help ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long-term care) for one of two residents sampled for PASARR review (Resident #4). The sample was 12. The census was 38. Review of the facility's Coordination and PASARR Program policy, dated 1/16/25, showed:-Intent: It is the policy of the facility to assure that all residents admitted to the facility receive a PASARR in accordance with State and Federal regulations;-Procedure included:-Preadmission screening for individuals with a mental disorder and individuals with intellectual disability. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' care plans were updated routinely and accurately reflected residents' code status orders. Do Not Resuscitate (DNR) orders were not accurately reflected in four of 22 sampled residents' care plans (Residents #20, #25, #7 and #37). The census was 38. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident with a pressure wound (skin or soft tissue injury that develops with prolonged periods of pressure over specific areas of the body) received necessary treatments and services to promote healing (Resident #15). The sample size was 12. The census was 38. Review of the facility's Treatment and Services to Prevent and Heal Pressure Ulcers policy, undated, showed:Intent: It is the policy of the facility to ensure it identifies and provides needed care and services that are resident centered, in accordance with the resident's preference, goals for care and professional standards of practice that will meet each resident's physician, mental, and psychosocial needs; -Procedure: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications kept in facility medication rooms were within the date of expiration and failed to remove one of 22 sampled resident's expired hospital discharge medications (Resident #22). Concerns were noted in one of one medication rooms during the survey period. The census was 38. Review of the facility's Storage of Medications policy, revised 1/16/25, showed:-Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing;-The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the pharmacy or destroyed;-The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner. 1. [...]

Inspectors wroteBased on observation and interview, the facility failed to post the nurse staffing information daily in a prominent place readily accessible to residents and visitors. The census was 38. Observations on 9/25/25 at 10:00 A.M., and 12:02 P.M., showed no staffing information posted in a prominent place. Observations on 9/26/25 at 9:00 A.M., and 11:00 A.M., showed no staffing information posted in a prominent place. During an interview on 9/26/25 at 11:15 A.M., the Assistant Director of Nursing (ADON) said the staffing has not been posted for about a month. It usually was posted in the lobby of the facility. The Activities Director was responsible for posting it but that person no longer works at the facility. The ADON did not know who currently was responsible for posting the staffing hours. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services consistent with acceptable standards of practice for one resident when staff failed to accurately assess and document a wounds appearance, odors, the condition of the surrounding skin, resulting in the failure to timely identify the worsening of a left heel wound. The resident was sent to the hospital for evaluation of the wound. The hospital staff assessed the wound and identified the wound to have necrotic (dead) skin, very malodorous (very foul odor), and the surrounding skin erythematous (abnormally red and inflamed). The hospital diagnosed the wound as osteomyelitis (infection of the bone) and gangrene (a serious condition that occurs when tissue dies due to a lack of blood flow or a bacterial infection) (Resident #1). The sample size was four. The census was 38. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff followed acceptable standards of nursing when staff failed to accurately assess open areas to the buttock and coccyx (tailbone) for one resident. When the wound was assessed by the wound care provider, the wounds were identified as stage III (full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed) pressure injuries. New treatment orders were given by the wound care provider, but not transcribed to the resident's physician orders or completed as ordered. (Resident #2). The sample size was four. The census was 38. Review of the facility's undated Treatment/Services to Prevent and Heal Pressure Ulcers policy, showed: -Intent: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from significant medication error by not administering the resident's seizure medication when an error resulted in the order being deleted from the physician order sheet, for at least three months, for one resident reviewed for hospitalization. This resulted in the resident having a seizure that resulted in hospitalization (Resident #1). The census was 39. Review of the facility's undated Physician's Services policy, showed: -Intent: It is the policy of the facility to provide Physician Services in accordance with State and Federal regulations: -A physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide orders for the resident's immediate care and needs; -Each resident will remain under the care of a physician; [...]

Inspectors wroteBased on interview and record review, the facility failed to complete comprehensive resident assessments on admission and at least annually for six of 12 residents sampled (Residents #101, #104, #102, #51, #52, and #53). The quarterly assessments had not been completed since year 2022 for some sampled residents. The census was 39. Review of the Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) version 3.0 Resident Assessment Instrument (RAI) User's Manual, showed: -For all non-admission assessments, the MDS completion date must be no later than 14 days after the Assessment Reference Date (ARD); -For the admission assessment, the MDS Completion Date must be no later than 13 days after the entry date; -Encoding Data: [...]

Inspectors wroteBased on interview and record review, the facility failed to complete quarterly resident assessments for nine of 12 residents sampled (Residents #55, #101, #104, #102, #51, #54, #151, #53, and #103). The quarterly assessments had not been completed since year 2022 for some sampled residents. The census was 39. Review of the Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) version 3.0 Resident Assessment Instrument (RAI) User's Manual, showed: -For all non-admission assessments, the MDS completion date must be no later than 14 days after the Assessment Reference Date (ARD). 1. Review of Resident #55's medical record, showed admitted [DATE]. Review of the resident's MDS records, showed a quarterly MDS, dated [DATE], in process. 2. Review of Resident #101's medical record, showed admitted on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete and transmit required Minimum Data Sets (MDS, a federally mandated assessment instrument completed by facility staff) as required for 11 of 12 sampled residents (Residents #55, #101, #104, #102, #51, #152, #153, #54, #53, #103, and #151) when the facility failed to ensure staff had the required credentials to submit and transmit MDS data. The facility failed to transmit data since February 2022. This had the potential to affect all residents who reside in the facility. The census was 39. Review of the MDS aversion 3.0 Resident Assessment Instrument (RAI) User's Manual, showed: -For all non-admission assessments, the MDS completion date must be no later than 14 days after the Assessment Reference Date (ARD); -For the admission assessment, the MDS Completion Date must be no later than 13 days after the entry date; [...]

Inspectors wroteBased on interview and record review, the facility failed to electronically submit to The Centers of Medicare and Medicaid services (CMS) complete and accurate direct care staffing information no less frequently than quarterly, for the 4 available quarters immediately preceding the annual survey. The census was 39. Review of the facility's Payroll Based Journal (PBJ) Staffing Data Report, showed the facility triggered for failing to submit data for: -Fiscal year quarter 1, 2023 (October 1 - December 31); -Fiscal year quarter 2, 2023 (January 1 through March 31); -Fiscal year quarter 3, 2023 (April 1 through June 30, 2023); -Fiscal year quarter 4, 2023 (July 1 through September 30, 2023). During an interview on 2/18/24 at 9:50 A.M., the Administrator said the facility does not submit PBJ reports. She did not think they had to. [...]

Inspectors wroteBased on interview and record review, the facility failed to demonstrate the development and implementation of corrective actions as part of their quality assurance and performance improvement (QAPI) activities when there was a known deficient practice related to the resident assessment completion and transmission, that had the potential to affect all residents that reside in the facility and had been an ongoing issue at the facility. The facility had been cited for their failure to complete and transmit resident assessments during their survey completed on 12/20/21 and achieved compliance on 2/3/22. During the current survey, review of the sampled resident records, showed the facility fell out of compliance with these same requirements as early as 2/25/22, only 22 days after reaching compliance and remained out of compliance. The sample was 12. The census was 39. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a water management program to reduce the growth/spread of Legionella (a bacterium that can live and grow in water systems and causes legionnaires disease, a severe form of pneumonia) and other opportunistic pathogens in the building's water system. This failure had the potential to affect all residents who reside in the facility. In addition, the facility failed to follow acceptable infection control practices during personal care for two of two residents observed to receive personal care (Residents #153 and #54) and failed to sanitize shared medical equipment per acceptable standards of practice between resident care for two of two residents observed to be transferred with a mechanical lift (Residents #54 and #53). The census was 39. The sample was 12. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a significant change in status assessment be completed within 14 days after a determination has been made that a significant change occurred for two of thee residents sampled who enrolled in a hospice program (Residents #153 and #154). The facility identified nine residents who received hospice services. The census was 39. 1. Review of Resident #153's medical record, showed: -admitted [DATE]; -Diagnoses included heart failure, chronic kidney disease and diabetes; -A hospice admission form, showed the resident admitted to hospice on 12/28/23. Review of the resident's Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) records, showed: -An admission MDS dated [DATE]; -A quarterly MDS in progress dated 2/22/24; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident assessment was accurately coded for three of three resident closed records reviewed for sampled residents with resident assessments completed and transmitted (Residents #7, #8, and #2). The census was 39. Review of the Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) 3.0 Nursing Home Comprehensive assessment, showed: -Section A2100 Discharge status: Complete if Identification information Entry/Discharge reporting A0310F is coded any of the following: -Discharge return not anticipated; -Discharge return anticipated; -Death in facility tracking record. 1. Review of Resident #7's medical record, showed: -discharged [DATE]; -A social service note, dated [DATE] at 12:08 P.M., resident discharged to a different nursing home today. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized comprehensive care plans to address specific needs of the residents for five of 12 sampled residents and one expanded sampled resident (Residents #52, #54, #1, #151, #152 and #153). The census was 39. 1. Review of the facility's updated Care Plan policy, showed: -Intent: It is the policy of the facility to promote seamless interdisciplinary care for our residents by utilizing the interdisciplinary plan of care based on assessment, planning, treatment, service, and intervention. It is utilized to plan for and manage resident care as evidenced by documentation from admission through discharge for each resident; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manor to prevent the risk of accidents and injury for two residents observed to be transferred using an unsafe technique, out of thee residents observed to be transferred (Residents #54 and #153). The census was 39. The sample was 12. 1. Review of the facility's undated Sit-to-Stand lift (mechanical lift that supports a resident to stand and transfer) policy, showed: -Sit-to-stand resident lifts are for residents who: Have good torso and upper-body strength, can hold up their neck and head, can hold on to the grips with at least one hand, are 25-75% weight bearing in their legs, ankles, knees and feet, and are cooperative; -Have the resident begin in a seated position on the edge of a bed or chair; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each nurse aide had no less than twelve hours of in-service education per year based on their individual performance review and calculated by their employment date rather than the calendar year, for 5 of 5 sampled Certified Nursing Assistants (CNA) sampled. The facility identified eight CNAs employed for more than a year. The census was 39. Review of the Facility Assessment Tool, dated 1/4/24, completed by the facility, showed: -Staff training, education, and competencies: Training and/or education is verified to assure staff are prepared to care for our residents. Competencies that are necessary to provide the level and types of support and care needed for our resident population are also verified; -CNA: Required in-service training for nurse aides: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored per acceptable standards of practice. The facility identified two medication/treatment carts. One of the two carts was checked for medication storage. Issues were found for 7 out of 12 insulin pens, undated. In addition, four topical ointments were unlabeled with a resident name. The census was 39. Review of the facility's undated Medication Cart Policy, showed: -The medication cart is to be clean and organized; -Over the counter medications are to be labeled when opened with the date on the bottle; -Staff to be checking expiration dates on all medications frequently. Review of the facility's undated insulin storage policy, showed: -Policy: to ensure resident medications are stored properly; -Procedure: [...]

Inspectors wroteBased on interview and record review, the facility failed to designate a person to serve as the Director of Dietary with the appropriate certification, when a consultant Registered Dietician (RD) was not employed full-time with the facility. This had the potential to affect all residents who consume meals at the facility. The census was 39. Review of the facility's director of dietary job description, showed: -Dietary Manager: -Evaluating kitchen equipment and replacing it as necessary; -Developing health and safety policies for the facility; -Creating procedures for preparing and storing food safely; -Interviewing and hiring kitchen employees; -Supervising kitchen employees as they prepare food; -Conducting employee performance evaluations; -Analyzing the needs of every resident, client, student, or patient in the facility; -Managing daily food service operations; [...]

Inspectors wroteBased on interview and record review, the facility failed to explicitly inform the resident or his or her representative of their right not to sign an arbitration agreement (a private process where disputing parties agree that one or several other individuals can make a decision about the dispute after receiving evidence and hearing arguments) as a condition of admission, or as a requirement to continue to receive care at the facility, for two of two residents sampled for review of the arbitration agreements (Resident #106 and #108). The facility identified 28 residents who currently resided in the facility with signed arbitration agreements. The census was 39. 1. Review of the facility's admission packet, showed: -Page 25: (initials) Alternative dispute resolution addendum: [...]

Inspectors wroteBased on interview and record review, the facility failed to designate one or more individuals with specialized training in infection prevention and control as the Infection Preventionist (IP) for the facility's infection prevention and control program. The census was 39. Review of the facility's Antibiotic Stewardship Program (ASP) policy, showed: -Infection preventionist: this person will be the hub of the ASP. They will have the knowledge and expertise to effectively develop, implement and monitor the ASP. During an interview on 2/19/24 at 11:15 A.M., the Director of Nursing (DON) said the facility has an IP, however the nurse has not completed all the infection control modules. The DON was uncertain how many training modules had been completed. During an interview on 2/19/24 at 2:42 P.M., the IP said she has been the facility infection preventionist as of 8/2023. [...]

Inspectors wroteBased on interview and record review, the facility failed to timely notify the resident's physician after a change in condition occurred for one resident (Resident #9). The sample was 12. The census was 39. Review of the facility's undated Change in Condition policy and procedure, showed: -A resident change in condition is a sudden deviation from the resident's baseline in physical, cognitive, behavioral or functional status; -The nurse will obtain a current set of vital signs and obtain the proper assessment needed to report to the physician; -The facility will promptly notify the residents responsible party and the physician of the change in condition. The facility will talk with the physician to obtain orders for appropriate treatment and monitoring; -The facility will promote family and the resident right to make choices about his/her own treatment; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who required assistance with activities of daily living (ADLs) received personal hygiene assistance in accordance with their needs (Resident #153), for one of two residents observed to receive personal care. The sample was 12. The census was 39. Review of the facility's undated Perineal care (cleansing of the surfaces to include the buttocks and genitals) Procedure, showed: -Gather necessary supplies; -Perform hand hygiene and put on gloves; -Gently clean around the perineal area, including the inner thighs and outside genitals; -Only wipe in a front to back motion; -Use a clean wipe for each stroke, wipe from front to back on both sides of the genitals; -Remove gloves and perform hand hygiene; -Assist the resident on to the side to expose the buttocks; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident with pressure ulcers (injury to the skin and underlying tissues as a result of pressure or friction) received services, consistent with professional standards of practice, to promote healing of the pressure ulcer when a certified nursing assistant (CNA) removed the dressing and failed to inform the nurse (Resident #54). This resulted in the resident's pressure ulcer being without treatment or protection from friction for three hours. The facility identified five residents with facility acquired pressure ulcers. The census was 39. Review of the facility's undated Physician Services policy, showed: -It is the policy of the facility to provide physician services in accordance to state and federal regulations; [...]

Inspectors wroteBased on interview and record review, the facility failed to complete comprehensive resident assessments using the Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, within 14 calendar days after admission into the facility and not less than every 12 months for seven of 12 sampled residents (Residents #155, #53, #203, #52, #202, #204 and #201). The census was 34. 1. Review of Resident #155's medical record, showed an admission date of 8/11/21. Review of the resident's MDS record, showed no admission MDS completed. 2. Review of Resident #53's medical record, showed an admission date of 5/5/21. Review of the resident's MDS record, showed no admission MDS completed.: 3. Review of Resident #203's medical record, showed an admission date of 2/4/10. Review of the resident's MDS record, showed -A quarterly MDS, completed 5/16/20; [...]

Inspectors wroteBased on interview and record review, the facility failed to assess residents using the quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, for 11 (Residents #53, #55, #103, #104, #105, #153, #155, #156, #201, #202 and #203) of 12 sampled residents. The census was 34. 1. Review of Resident #53's medical record, showed: -An admission date of 5/5/21; -No quarterly MDS assessment completed. 2. Review of Resident #55's medical record, showed: -An admission date of 9/6/20; -No quarterly MDS assessments completd. 3. Review of Resident #103's medical record, showed: -An admission date of 12/1/19; -A quarterly MDS, completed 9/2/20; -No further MDS assessments completed. 4. Review of Resident #104's medical record, showed: -An admission date of 11/18/17; -A quarterly MDS, completed 9/2/20; -No further MDS assessments completed. 5. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete and transmit required Minimum Data Sets (MDS) a federally mandated assessment instrument completed by facility staff, for 11 (Residents #53, #55, #103, #104, #105, #153, #155, #156, #201, #202 and #203) of 12 sampled residents. The census was 34. 1. Review of Resident #53's medical record, showed: -admitted on [DATE]; -No MDS assessments completed. 2. Review of Resident #55's medical record, showed: -admitted on [DATE]; -No MDS assessments completed. 3. Review of Resident #103's medical record, showed: -admitted on [DATE]; -A quarterly MDS, completed 9/2/20; -No further MDS assessments completed. 4. Review of Resident #104's medical record, showed: -admitted on [DATE]; -A quarterly MDS, completed 9/2/20; -No further MDS assessments completed. 5. Review of Resident #105's medical record, showed: -admitted on [DATE]; [...]

Inspectors wroteBased on interview and record review, the facility failed to implement an effective quality assurance (QA)/quality assurance performance improvement (QAPI) program when they did not implement appropriate interventions to correct on-going, systemic issues. The sample size was 12. The census was 34. Review of the facility Quality Assurance and Performance Improvement (QAPI) policy, undated, showed: Intent: -These policies are intended to ensure the facility develops a plan that describes the process for conducting QAPI/QAA (Quality Assessment and Assurance) activities, such as identifying and correcting quality deficiencies as well as opportunities for improvement, which will lead to improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life, and resident safety; Policy: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the quality assurance and assessment (QAA) committee held quarterly quality assurance performance improvement (QAPI) meetings, and/or consisted of the required committee members. The census was 34. Review of the facility QAA Committee policy, undated, showed: Intent: -These policies are intended to ensure the facility develops a plan that describes the process for conducting QAPI (Quality Assurance and Performance Improvement)/QAA activities, such as identifying and correcting quality deficiencies as well as opportunities for improvement, which will lead to improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life, and resident safety; Policy: [...]

Inspectors wroteBased on interview and record review, the facility failed to implement written policies and procedures to prevent abuse and neglect by failing to ensure the completion of proper screenings of criminal backgrounds, the employment disqualification list (EDL), and federal indicator checks (to ensure the employee is in good standing with the nurse aide (NA) program) for six of ten employee records reviewed. The census was 34. Review of the facility's Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property Prevention policy, undated, showed: -Intent: The facility will develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property. [...]

Inspectors wrote4. Review of Resident #155's medical record, showed: -admitted on [DATE]; -Diagnoses included diabetes, high blood pressure and stroke. Review of the resident's care plan, last updated 10/1/21, showed no information regarding the use of side rails. Observation on 12/14/21 at 9:35 A.M., showed the resident sat on his/her bed. Quarter length side rails were raised on both sides of the bed. Observation on12/15/21 at 9:25 A.M., 12/16/21 at 10:56 A.M. and 2:52 P.M., and 12/17/21 at 6:37 A.M. and 9:44 A.M., showed the resident lay on his/her back in his/her bed. Quarter length side rails were raised on both sides of the bed. 5. During an interview on 12/20/21 at 8:56 A.M., the administrator and Nurse A said care plans should be completed upon admission, quarterly and as needed. The care plan should reflect the resident's needs. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff followed physician parameter orders for high/low blood glucose levels and/or failed to ensure residents with orders for routine blood glucose levels had physician parameters and failed to ensure one of those four residents with an order for heel protectors wore them (Residents #156, #205, #102 and #56). In addition, the facility failed to ensure staff followed their neurological assessment policy after one resident had a fall with a head injury and failed to ensure that same resident had a pressure ulcer dressing in place prior to transferring the resident from bed into a chair (Resident #201). The census was 34. 1. Review of Resident #156's admission face sheet, showed: -admission date of 3/29/19; [...]

Inspectors wroteBased on interview and record review, the facility failed to designate a full-time Registered Nurse (RN) as the Director of Nursing (DON), and failed to ensure an RN was scheduled to work 8 consecutive hours a day, 7 days a week. The census was 34. Review of the facility-wide assessment, undated, showed: Staffing Plan: DON: 1 DON RN full-time. Review of the Director of Nursing Job Description: Ensuring Nursing Personal to Perform Best Patient Care, undated, showed: -A DON, who is also known as a nursing director, becomes a person whose job is to ensure the nursing personnel works. The DON job description must include managing healthcare facilities and services, ensuring patient care, etc. He/she also works to handle administrative tasks including budgeting. A DON usually makes use of the DON description template as a reminder of his/her tasks. DON Job Description Information: [...]

Inspectors wroteBased on interview and record review, the facility failed to document the date the facility-wide assessment was developed, if and when it had been reviewed by the QAA (quality assurance and assessment)/QAPI (quality assurance and performance improvement) committee, the date of the last annual review and/or the date of the last revision. The facility-wide assessment did not include the need for a Registered Nurse (RN) for at least 8 consecutive hours a day 7 days a week, its staffing plan and did not include the most recent information regarding their emergency water sources. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure 9 of 10 staff hired within the past 12 months received their two-step tuberculin skin test, and failed to ensure 9 of 12 sampled residents and two of two expanded sample residents received their admission two-step tuberculin skin test and or annual tuberculosis (TB) screening/assessment. (Residents #52, #53, #55, #56, #102, #153, #155, #156, #201, #202 and #204). The census was 34. Review of the facility Infection Control-Tuberculosis (TB) Screening Program, undated, showed: Intent: -It is the policy of the facility to ensure the implementation of a Tuberculosis Screening Program in accordance with State and Federal Regulations, and the Centers for Disease Control and Preventions (CDC) guidelines; Procedure: 1. The facility infection control coordinator or designee is responsible for the TB program; 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident personal funds were placed in an interest-bearing account for one of one resident account reviewed (Resident #209). The census was 34. Review of the facility's Protection/Management of Personal Funds policy, undated, showed: -It is the policy of the facility to protect and manage the personal funds of the resident in such a manner to acknowledge and respect resident rights; -Residents whose care is funded by Medicaid: -The facility will deposit the residents' personal funds in excess of $50.00 in an interest bearing account that is separate from any of the facility's operating accounts, and that credits all interest earned on resident's funds to that account; -There will be a separate accounting for each resident's share. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and report allegations of resident abuse to the Department of Health and Senior Services (DHSS) as required, within a two-hour time frame, for one resident (Resident #203). The sample was 12. The census was 34. Review of the facility's Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property Prevention policy, undated, showed: -Intent: The facility will develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property, to include the use of physical or chemical restraints. The purpose is to assure that the facility is doing all that is within its control to prevent occurrences; [...]

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate allegations of abuse for three residents who were involved in resident altercations (Residents #201, #202, and #203). The sample was 12. The census was 34. Review of the facility's Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property Prevention policy, undated, showed: -Intent: The facility will develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property, to include the use of physical or chemical restraints. The purpose is to assure that the facility is doing all that is within its control to prevent occurrences; -Physical abuse includes hitting, slapping, pinching, pulling, and kicking; [...]

Inspectors wroteBased on interview and record review, the facility failed to investigate a fall and an injury of unknown origin for two of 12 sampled residents (Residents #104 and #101). The census was 34. Review of the facility's undated policy on Reporting Accidents and Incidents, showed the following: -Intent: It is the policy of the facility to report Accidents and Incidents in accordance to State and Federal regulations; Procedure: -1. The Incident and Accident Reporting System will include a comprehensive process which will allow for the following: -a. Collection of the incident and accident occurrence; -b. Investigate incidents and accidents; -c. Evaluate injuries of unknown source; -d. Track and trend incidents and accidents; -2. The Event Report will be completed by the nurse assigned to the resident at the time of the event or a designated nurse; -3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure scheduled pain medication was available and/or administered as ordered, and to document measures taken by staff to obtain the medication for one resident (Resident #204). The sample was 12. The census was 34. Review of Resident #204's medical record, showed: -Diagnoses included sciatica (symptom of a problem with the sciatic nerve (the largest nerve in the body), causing pain, weakness, numbness or tingling), pain in left shoulder, osteoarthritis and depression; -An order, dated 8/13/20, for tramadol (narcotic) 50 milligram (mg) tablet, give two tabs by mouth every six hours as needed for pain; -An order, dated 9/16/21, for Lidoderm (lidocaine, used to relieve pain) 5% adhesive patch, medicated, every 12 hours, on at 8:00 A.M. and off at 8:00 P.M. for pain. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to complete required assessments and maintain proper documentation for the use of side rails/bed rails for two of 12 sampled residents (Residents #155 and #156). The facility identified 11 residents who utilized side rails. Of the 11 residents who utilized side rails, two were sampled, and problems were identified with both residents. The census was 34. Review of the facility's undated Bedrails policy and procedure, showed: -Policy: The facility shall provide adequate management of Bedrails to ensure that residents attain or maintain the highest practicable physical, mental and psychosocial well-being. -Procedure: -The facility will attempt to use appropriate alternatives prior to installing a side or bed rail; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to complete an inspection of bed frames, mattresses and side rails as part of a regular maintenance program to identify areas of possible entrapment for two residents (Residents #155 and #156) of 12 sampled residents to reduce the risk of accidents. The facility identified 11 residents who utilized side rails. Of the 11 residents, two were sampled, and problems were identified with both residents. The census was 34. Review of the facility's undated Bedrails policy and procedure, showed: -Policy: The facility shall provide adequate management of bedrails to ensure that residents attain or maintain the highest practicable physical, mental and psychosocial well-being. -Procedure: -The facility will attempt to use appropriate alternatives prior to installing a side or bed rail; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the most recent abbreviated survey results in a place readily accessible to residents, family members and the public. The facility also failed to post notices in a prominent location of the availability of the reports, and failed to maintain reports from complaint investigations made during the three preceding years for review upon request. The census was 34. Observations on all days of the survey on 12/14/21 through 12/17/21, and 12/20/21, showed: -No postings regarding the availability of the most recent survey results or the prior three years; -In the corner of the front dining room, a survey binder hung in a basket on the wall. [...]

Inspectors wroteBased on observation and interview, the facility failed to post required nurse staffing information which included the total number of staff and the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, per shift, on a daily basis. The census was 34. Observations of common areas throughout the facility on 12/14, 12/15, 12/16, 12/17 and 12/20 at different times, showed no staffing information posted. During an interview on 12/20/21 at 12:45 P.M., the administrator and nurse A said the staffing information had not been posted as required. Nurse A said he/she was responsible to post the daily staffing hours and had posted the information a few times since he/she started on 9/14/21, but stopped posting it. It has not been posted since the survey began on 12/14/21.

Inspectors wroteBased on interview and record review, the facility failed to ensure they maintained an effective system to track influenza and pneumococcal vaccines for 12 of 12 sampled residents (Resident #52, #53, #55, #104, #105, #153, #155, #156, #201, #202, #203, and #204). This affected all residents residing in the facility. The census was 34. Review of the facility's Infection Control-Influenza and Pneumococcal Immunizations for Residents policy, undated, showed: -Intent: It is the policy of the facility to ensure that the resident receives Influenza and Pneumococcal immunizations, in accordance with State and Federal Regulations, and national guidelines; -Procedure; -Influenza Immunization: 1. Before offering the influenza immunization, each resident and or the resident representative receives education regarding the benefits and potential side effects of the immunization; 2. [...]