Florissant Valley Health & Rehabilitation Center

Inspectors wroteBased on interview and record review, the facility failed to provide services per acceptable standards of practice for one resident (Resident #1), when the facility failed to follow physician orders for a new medication to treat nerve pain for 10 days after the resident returned from an appointment with the neurologist (physician who treats the nervous system). The sample size was 4. The census was 79. The administrator was notified on 10/29/25, of the past non-compliance. The administrator of the facility investigated immediately 10/12/25, in-serviced all staff on following up on resident outside appointments to ensure paperwork is received and reviewed when a resident returns from an appointment for new and or changed orders. [...]

Inspectors wroteBased on interview and record review, the facility failed to adequately treat pain for one resident (Resident #2) who was actively dying. The sample size was three. The census was 72. Review of the facility's pain management policy, dated 11/15/22, showed:-Policy: The Facility will use a systematic approach to pain management; Recognition, evaluation, treatment, and monitoring of pain. Individuals experiencing pain may receive pharmalogical/non-pharmalogical interventions to assist in pain management. The Facility will provide employees education on pain management & opioid (class of drugs used for pain relief) overdose;-Recognition included recognizing when a resident was experiencing pain and identify circumstances when pain can be anticipated; Evaluate the resident for pain on admission and routinely; [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate medical records as per their policies for one resident of three sampled residents (Resident #2). The facility failed to document assessments for the actively dying resident; failed to accurately document analgesics (pain medication) on narcotic accountability sheets and on the medication administration records; failed to document when morphine sulfate solution (opioid for moderate to severe pain) was delivered and then wasted by facility staff; failed to document when the resident ran out of morphine including notification to hospice and pharmacy; failed to document interactions with hospice staff and failed to document when a new bottle of morphine was delivered by hospice staff from a local pharmacy. The census was 72. Review of the facility's Medication ordering and receiving from pharmacy; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was administered alprazolam (Xanax, used for anxiety) as ordered. In addition, the facility failed to ensure the physician was notified timely when the medication was not delivered and the resident missed multiple doses. The resident experienced anxiety and tearfulness as a result (Resident #3). The sample was 4. The census was 78. Review of the controlled substance prescriptions policy, dated 8/2014, showed: -Policy: -Before a controlled drug can be dispensed, the pharmacy must be in receipt of a clear, complete and signed written prescription from a person lawfully authorized to prescribe. A chart order is not equivalent to a prescription for controlled drugs. Therefore, the prescriber issuing the chart order must also provide the pharmacist with a valid prescription. [...]

Inspectors wroteSee the deficiency cited at Event H8S612. Based on interview and record review, the facility failed to ensure one resident (Resident #403) was provided a safe discharge home, by failing to ensure medical equipment was provided on the day of discharge and failing to educate the resident and family member on the use of the medical equipment. The sample was 23. The census was 75. Review of the facility's discharge plan/summary policy, dated 11/1/2018, showed: -Policy: An interdisciplinary summary is completed on a resident upon discharge to assure the continuum care needs of the resident are met; -Guidelines: Upon notification of impending discharge, the Interdisciplinary Team (IDT) should be notified to allow staff the opportunity to educate and implement a safe discharge. Social work should coordinate the discharge planning process. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide reasonable accommodation of individual needs and preferences by failing to ensure call lights were in reach for six residents (Residents #12, #23, #174, #20, #175 and #6). The facility also failed to have one resident's communication device within reach (Resident #126). The sample was 19. The census was 83. 1. Review of Resident #12's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/19/24, showed: -Severe cognitive impairment; -Always incontinent of bowel and bladder; -Required substantial assistance from staff for toileting and lower body dressing; -Required moderate assist from staff from lying to sitting at the side of the bed , sitting to standing and chair to bed transfers; [...]

Inspectors wroteBased on interview and record review, the facility failed to follow general accounting principles by failing to employ proper bookkeeping techniques to track the amount of cash on hand used for resident withdrawals from the resident trust account. This affected 44 residents whose funds were handled by the facility. The census was 83. Review of the facility's petty cash daily log sheets, showed no ongoing tracking of the total amount of cash on hand at any given time and no monthly reconciliation. During an interview on 11/21/24 at 1:58 P.M., the Business Office Manager (BOM) said the facility keeps cash on hand for resident requests for cash. There is no set amount of cash kept on hand and the amount of cash available varies at any given time. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were changed in a timely manner (Residents #23, #25 and #44), failed to ensure residents received a minimum of two showers per week and activities of daily living (ADL) care as needed (Residents #2, #36, #45, #54, #66, #276 and #126), and failed to ensure residents were repositioned in bed as needed (Residents #126 and #41 ). The sample was 19. The census was 83. Review of the facility's ADL bathing policy, dated 7/21/22, showed: -Policy: nursing staff will assist in bathing residents to promote cleanliness and dignity. The charge nurse will be made aware of residents who refuse bathing; -Procedure: assist resident into the shower. Encourage them to hold onto to safety bars. Encourage resident to bathe him/herself and assist as needed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a sufficient amount of nursing staff was available to meet the needs of residents, resulting in a resident left in bed (Resident #20), meals not delivered timely and served cold (Residents #54 and #40), residents not changed timely (Resident #25), and residents not receiving showers in accordance with their needs and preferences (Residents #20, #54, and #2). The sample was 19. The census was 83. 1. Review of the facility's Facility Assessment, revised 7/20/24, showed: -Assistance with activities of daily living (ADL) monthly average included: -Bed mobility sit to lying, mobility sit to stand, bathing, transfers, and toileting: 34 with supervision/partial/moderate assistance, and 30 dependent/maximum assistance; -Eating: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure room trays were delivered to residents at a safe and palatable temperature affecting six residents (Residents #54, #40, #70, #275, #276 and #274). The sample was 19. The census was 83. Review of the facility's food safety and food handling policy, revised 8/16/23, showed: -Policy: food handling practices shall be consistent with Food and Drug Administration (FDA) food code guidelines and comply with federal and state regulations governing food safety and prevention of foodborne illness; -Procedure: food handling practices shall be completed in a manner to protect food safety and avoid cross-contamination. Minimum internal temperatures for meat should be 145 degrees Fahrenheit (F). 1. Review of Resident #54's medical record, showed: [...]

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 gastrostomy tubes (g-tube, a tube that is surgically inserted into the abdomen and is used for liquid nutrition and medications), wounds requiring treatments, peripherally inserted central catheter (PICC, a thin tube inserted into the vein that is utilized for medications and fluids) (Residents #126, #3, #14, #41 and #27). [...]

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 control program. The census was 83. Review of the facility's Surveillance of Healthcare Associated Infections policy, reviewed 10/7/21, showed: -Policy: Surveillance for Healthcare Associated Infections (HAI) will be completed to calculate baseline rates, detect outbreaks, track progress, and to determine trends to help prevent the development or spread of infection; -Responsibility: Director of Nursing (DON), infection control designee, and licensed nurses. During an interview with on 11/20/24 at 2:00 P.M., the DON said she did not have the IP certificate completed. She had worked on it all night. The previous IP left about one month ago. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to treat three residents (Resident #174, Resident #23, and Resident #55) with dignity by leaving a resident exposed to the hallway, speaking to residents in an unprofessional manner when they referred to residents as feeders in front of residents, and staff stood over residents while assisting residents with their meal. The sample was 19. The census was 83. Review of the facility's Residents' [NAME] of Rights, showed your rights and protections as a nursing home resident: -As a nursing home resident, you have certain rights and protections under federal and state law that help ensure you get the care and services you need; -You have the right to be treated with dignity and respect, as well as make your own schedule and participate in the activities you choose. 1. Review of Resident #174's medical records, showed; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were assessed to self-administer medications and to ensure staff adequately supervised residents during medication administration (Residents #26 and #128). The sample was 19. The census was 83. Review of the facility's Medication Administration - General Guidelines, dated December 2017, showed: -Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so; -Administration: -Medications are administered in accordance with written orders of the prescriber; -When medications are administered by mobile cart taken to the resident's location (room, dining area, etc.) medications are administered at the time they are prepared; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure third party liability (TPL) forms were completed within 30 days for the final accounting for residents who expired. This affected three residents who expired and had money in their accounts (Residents #133, #131, and #132). The census was 83. Review of the facility's Business Office - Resident Trust Fund Policy and Procedure, undated, showed: -Upon the discharge or passing of the resident, funds shall be disbursed as follows: --Medicaid residents: All personal funds must be reported to the State based on regulatory requirements involving estate recovery. These funds can only be released by the State or made payable directly to a mortuary to cover any unpaid funeral expense. A copy of an invoice reflecting the unpaid balance must be provided. 1. Review of Resident #133's resident fund account, showed the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, comfortable, homelike environment by failing to address water stains on the ceiling near the window, peeling wallpaper and flaking paint on the ceiling due to water damage in one resident room which two residents shared (Resident #23 and #174). The sample was 19. The census is 83. Review of Resident #23's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/26/24, showed: -The resident is rarely or never understood; -Diagnoses included heart disease, kidney disease, diabetes, stroke and dementia. Review of Resident #174's medical records, showed; -Diagnoses included stroke, dysphagia (difficulty swallowing), weakness and heart disease. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify a representative of the State Long-Term Care (LTC) Ombudsman of resident transfers and discharges. The census was 83. Review of the facility's Discharge/Transfer - Involuntary policy, revised 10/7/21, showed: -Policy: Transfer and discharge includes movement of a resident to a bed outside of the facility whether that bed is in the same physical plant or not. Transfer and discharge does not refer to movement of a resident to a bed within the same certified facility; -The policy did not provide any guidance related to notification to the Ombudsman regarding resident transfers and discharges. Review of the facility's Discharge Plan/Summary - Voluntary policy, revised 10/7/21, showed no guidance related to notification to the Ombudsman regarding resident transfers and discharges. During an interview on 11/13/24 at 12:29 P.M. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #403) was provided a safe discharge home, by failing to ensure medical equipment was provided on the day of discharge and failing to educate the resident and family member on the use of the medical equipment. The sample was 23. The census was 75. Review of the facility's discharge plan/summary policy, dated 11/1/2018, showed: -Policy: An interdisciplinary summary is completed on a resident upon discharge to assure the continuum care needs of the resident are met; -Guidelines: Upon notification of impending discharge, the Interdisciplinary Team (IDT) should be notified to allow staff the opportunity to educate and implement a safe discharge. Social work should coordinate the discharge planning process. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided met professional standards by not providing transportation to two residents' medical appointments (Resident #66 and Resident #12). The sample was 19. The census was 83. 1. Review of Resident #66's medical record, showed diagnoses that include diabetes, morbid obesity, shortness of breath, obstructive sleep apnea (a condition that cause breathing to slow down or stop during sleep), heart failure and difficulty walking. Review of the resident's progress notes, showed: -On 8/28/24 at 3:10 P.M., Follow up with the pulmonary doctor and neurosurgery doctor forwarded to social worker; -On 10/9/24 at 2:56 P.M., The resident's pulmonary doctor's appointment rescheduled for 10/23/24 at 12:30 P.M. The resident was notified of new appointment. Will arrange transport. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received care consistent with professional standards by failing to identify one resident's wound and obtain a treatment order (Resident #14) and obtain proper skin care treatment orders for one resident (Resident # 66). The sample was 19. The census was 83. Review of the facility's Skin Integrity policy, reviewed 7/5/24, showed: -Purpose: to establish best practice guidelines for skin integrity monitoring and maintenance to reduce potential risk of skin breakdown where clinically appropriate; -Policy: Skin evaluations shall be completed upon admission and routinely, as per the care plan, to monitor skin integrity; Skin integrity risk factors will be evaluated upon admission and routinely, as per the care plan; Appropriate interventions will be initiated based on the risk factors identified; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received respiratory care consistent with professional standards of practice when staff failed to follow physician orders for oxygen use for two residents (Residents #46 and #14) and failed to consult the physician regarding oxygen administration at a higher rate than what was ordered for one resident (Resident #46). The sample was 19. The census was 83. Review of the facility's Oxygen Administration and Storage policy, issued 1/1/24, showed: -Purpose: To ensure staff follow safety guidelines and regulation for storage and use of oxygen; -General guidelines included: -Pulse Oximetry (a device used to determine oxygen saturation, the percentage of oxygen in the blood): -Residents who have oxygen orders should have oxygen saturation levels measured by oximetry. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who received dialysis (the clinical purification of blood as a substitute for the normal function of the kidney) had documented assessments and monitoring related to dialysis. The facility identified seven residents who received dialysis, and two residents were sampled (Resident #275 and #70). The sample was 19. The census was 83. On 11/21/24 at 10:56 A.M., an email was sent to the Assistant Director of Nursing for a policy regarding care for a resident receiving dialysis service. As of the exit date, on 11/22/24, no policy was provided. 1. Review of Resident #70's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/6/24, showed: -admission date 10/6/24; -Cognitively intact; -The resident is receiving hemodialysis while at the facility; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were stored in accordance with currently accepted professional principles when expired medications were in the nurse medication carts and in the medication supply rooms. The facility had two medication rooms and four medication carts. The census was 83. Review of the facility's Medication Storage policy, dated 11/18, showed: -Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications; -Procedures: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure resident records were complete and accurately documented when staff failed to document the circumstances surrounding a discharge from the facility for one resident (Resident #72) and when an employee documented completion of neurological assessments for one resident (Resident #35) during shifts the employee did not work. The sample was 19. The census was 83. 1. Review of Resident #72's medical record, showed: -admission date 5/29/24; -Diagnoses included seizures, diabetes, heart failure, atrial fibrillation (irregular heartbeat), dementia, schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves) and bipolar disorder (mood disorder with intense mood swings). -discharged [DATE]; [...]

Inspectors wroteSee deficiencies cited at NRN712 Based on observation, interview and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service by not designating a person to serve as the Director of Food and Nutrition Services after the Dietary Manager (DM) was terminated on 7/30/24. This deficient practice had the potential to affect all residents in the facility. The census was 76.

Inspectors wroteSee deficiencies cited at NRN712 Based on observation, interview and record review, the facility failed to keep the kitchen equipment clean and floors free of debris, grease, and grime by not following their monthly, weekly, and daily cleaning lists. Additionally, the facility failed to store food in a safe and sanitary manner to prevent potential cross-contamination and failed to label and date food items. This had the potential to affect all residents who consumed food from the facility kitchen. The census was 76.

Inspectors wroteSee deficiencies cited at NRN712 Based on observation and interview, the facility failed to maintain an effective pest control program to control the presence of flies and gnats in the kitchen. The census was 76.

Inspectors wroteBased on observation, interview and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service by not designating a person to serve as the Director of Food and Nutrition Services after the Dietary Manager (DM) was terminated on 7/30/24. This deficient practice had the potential to affect all residents in the facility. The census was 76. Review of the facility's Sanitation Inspection policy, last reviewed on 11/27/23, showed: -Policy: Nutritional Services shall ensure a clean and sanitary work environment; to promote and protect food safety; and to maintain compliance with Federal, State, and Local regulations governing food sanitation and safety; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to keep the kitchen equipment clean and floors free of debris, grease, and grime by not following their monthly, weekly, and daily cleaning lists. Additionally, the facility failed to store food in a safe and sanitary manner to prevent potential cross-contamination and failed to label and date food items. This had the potential to affect all residents who consumed food from the facility kitchen. The census was 76. Review of the facility's refrigeration policy, last revised 8/16/23, showed: -Policy: Ensure food storage and safety practices are maintained and monitored and comply with Federal and State regulations governing food storage and safety; -Refrigeration units shall have temperatures monitored twice daily by the Manager or his/her designee; [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain an effective pest control program to control the presence of flies and gnats in the kitchen. The census was 76. Observation of the kitchen on 8/12/24 at 9:42 A.M., showed several flies and gnats throughout the food prep areas of the kitchen, outside of the walk-in cooler, and inside the dry food storage room. There were flies and gnats outside of the walk-in cool, in the dishwasher area, and outside of the ice machine. There was a swarm of gnats over the steam table, the dining room pass through window and under the disinfecting sinks around the grease trap. There were also gnats floating in and swarming around a large, clear rectangular container which was filled with approximately three inches of cloudy water. The container was underneath a large industrial food steamer. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their abuse and neglect policy for employee screening. The facility failed to re-check an employee's criminal background and federal indicator (identifies when a staff person who has ever held a certified nursing assistant (CNA) certificate, has ever been found to have abused, neglected, or misappropriated resident property) through the state nurse aide registry prior to allowing that employee to return to work in the facility after employment had been terminated, for one employee. The census was 91. Review of the facility's Abuse Prevention Policy, revised 10/21/22, showed: Policy: The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care consistent with professional standards of practice to prevent 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 of three sampled residents by not frequently repositioning the resident and not providing incontinence care in a timely manner (Resident #5). The census was 91. Review of the facility's Wound Management policy, last reviewed on 11/15/22, showed: -Policy: To promote wound healing of various types of wounds, the facility will provide evidence-based treatments in accordance with Standards of Practice and Physician Orders; -Wound Treatments will be provided in accordance with physician's order: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to treat each resident with respect and dignity, in a manner and in an environment that promoted maintenance or enhancement of his/her quality of life when staff entered the resident's room and unplugged his/her TV without the resident's permission while the resident was watching TV (Resident #19). The census was 72. Review of the Residents' Rights signage posted throughout the building, showed: -Right to a Dignified Existence; -Right to Self-Determination. Review of Resident #19's quarterly Minimum Data Set, (MDS) a federally mandated assessment instrument completed by facility staff, dated 5/16/23, showed: -Cognitively intact; -Diagnoses included high blood pressure, stroke, dementia, hemiplegia (paralysis on one side of the body), depression and anxiety. Review of the resident's care plan, undated, showed: -Focus: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents could safely administer their own medications for three residents observed with medications in their room or left at their bed side (Residents #36, #59 and #77). The census was 72. Review of the facility's Self-Administration of Medications policy, dated 12/2017, included the following: -Policy: In order to maintain the resident's highest level of independence, residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self administer; -Procedures: -A. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide reasonable accommodations of individual needs and preferences by failing to ensure call lights were in reach for two residents (Residents #27 and #40). The census was 72. 1. Review of Resident #27's quarterly MDS, dated [DATE], showed: -Mild cognitive impairment; -Required total staff assistance for transfers and extensive staff assistance for moving about the facility; -Diagnoses included high blood pressure, diabetes, stroke, dementia, hemiplegia (paralysis on one side of the body), anxiety and depression. Observation and interview 6/5/23 at 9:57 A.M., showed the resident lay in bed. The call light was under the resident's bed. The resident said the call light was not usually in reach. It didn't do him/her any good anyway. Observation on 6/7/23 at 6:00 A.M., showed the resident lay in bed. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a free basic haircut for Medicaid residents (Residents #3, #24 and #26). This had the potential to affect all Medicaid residents. The census was 72. Record review of the Missouri Department of Social Services, MO Health Net Division State Regulations for Medicaid Reimbursement for Long Term Care Facilities, showed the following: -13 CSR 70-10.010 (5) Covered Supplies, Items and Services. All supplies, items and services covered in the per-diem rate must be provided to the resident as necessary. Supplies and services which would otherwise be covered in a per diem rate but which also are billable to the Title XVIII Medicare program must be billed to that program for facilities participating in the Title XVIII Medicare program. Covered supplies, items and services include, but are not limited to, the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their abuse and neglect policy for employee screening. The facility failed to check new employees' criminal background prior to employment for three out of ten employee files reviewed. The census was 72. Review of the facility's Abuse Prevention policy, revised 10/21/22, included: -Policy: The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to facility staff; -Screening: The facility will pre-screen all potential new employees. 1. Review of the Human Resource (HR) Specialist's employee file, showed: -Date of hire: 10/4/22; -Family Care Safety Registry (FCSR, can qualify as a criminal background check, in addition to other required checks) completed on 6/7/23. . 2. Review of [NAME] X's employee file, showed: -Date of hire: 12/29/22; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents that required assistance with activities of daily living (ADL) receive necessary services to maintain adequate personal hygiene and grooming for three residents (Resident #181, Resident #69 and Resident #32). The sample was 30. The census was 72. Review of the facility's Activities of Daily Living Bathing policy, dated 7/21/22, showed: -Policy: Nursing staff will assist in bathing residents to promote cleanliness and dignity; The charge nurse will be made aware of residents who refuse bathing; -Responsibility: Nursing assistant, charge nurse, nursing administration, and Director of Nursing (DON); -Procedure: -Equipment and Supplies: -Shower Chair -Lotion, deodorant, comb and hairbrush; -Face cloth & bathing towels; -Gown, pajamas, or outfit; -Personal Protective Equipment (PPE); [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an ongoing program to support residents in their choice of activities to meet the interests and well-being for two residents when staff failed to provide one on one (1:1) visits for one resident who preferred to stay in their room, and an alternate means of watching TV when the facility's cable provider was out of service. (Resident #27 and Resident #181). The sample was 30. The census was 72. 1. Review of Resident #27's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/3/22, showed: -Mild cognitive impairment; -Activity Preferences: -How important is it to keep up with the news: Very important; -How important is it participate in religious services: Very important; -How important is listen to music: Somewhat important; [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure staff promptly identified, documented and notified the physician of one resident with an open area on the coccyx (the small triangular bone at the base of the spine). Five resident skin assessments were completed and problems were found with one (Resident #42). The census was 72. Review of the facility's Skin Management Guidelines Practice Guidelines, dated 2/2016 and last revised on 7/2017, showed: -Purpose: -To identify at risk residents for potential breakdown or ulcerations; -To prevent breakdown issues; -To provide treatment that promotes prevention of ulcerations and healing of existing ulcerations; -Risk Factors: -Impaired mobility; -Cognitive impairment; -Exposure of skin to urinary or fecal incontinence; -Residents With Skin Impairments Will Have: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement safety interventions for one resident, who was assessed as cognitively impaired, nonverbal and a high risk to elope/wander. The resident signed himself/herself out multiple times without nursing staff's knowledge, and on one occasion staff found him/her, uninjured about 0.2 miles near a convenience store located near a busy intersection (Resident #70). Additionally, staff failed to ensure one resident, who required limited assistance to transfer, was transferred using a gait belt (Resident #32). The census was 72. 1. Review of Resident #70's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/16/23, showed: -admitted on [DATE]; -Hearing: Minimal difficulty; -Vision: Moderately impaired; -Speech Clarity: No speech - absence of spoken words; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident #52) who received tube feeding (supplies liquid nutrition) through a gastrostomy tube (G-tube, a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) received the appropriate treatment and services. The sample size was 30. The census was 72. Review of the facility's Continuous Tube Feeding policy, dated February 2016, showed: -To provide nourishment to the resident who is unable to obtain nourishment orally; -Procedure: -Verify physician order for feeding; -Gather necessary equipment for procedure; -Identify resident and explain procedure; -Provide privacy; -Perform hand hygiene and apply gloves; -Wear clean gloves; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to administer medications with a less than five percent medication error rate. Out of 25 opportunities for error, two errors occurred, resulting in an 8% medication error rate (Resident #55). The sample size was 30. The census was 72. Review of Resident #55's quarterly Minimum Data Set, a federally mandated assessment instrument completed by facility staff, dated 5/24/23, showed: -Clear speech, distinct intelligible words; -Usually understood; -Usually understands; -Extensive assistance of one person required for bed mobility, transfers, dressing and bathing; -Diagnoses of diabetes mellitus (low/high blood sugar), hemiplegia (partial or total paralysis on one side of the body)/hemiparesis (weakness on one side of the body). Review of the resident's physician's order sheet, showed the following orders: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident had the opportunity to receive the Pneumococcal vaccine, unless documentation showed the vaccine was medically contraindicated, refused or the resident was already immunized. The facility failed to offer the Pneumococcal vaccine for two out of five residents sampled (Resident #24 and Resident #32). The census was 72. Review of the facility's Pneumococcal vaccine policy, dated 4/28/22, showed: -The opportunity to receive the Pneumococcal vaccine will be extended to all residents. The facility will provide pertinent information regarding the risks and benefits of receiving the vaccine; -Procedure: -The residents will be offered the Pneumococcal vaccine upon admission; -Administration of additional doses will be completed in accordance with Centers of Disease Control (CDC) guidelines; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a functioning call light system with working audio and visual components for two of 30 sampled residents. (Residents #32 and #181). The facility failed to provide alternative or assistive devices to dependent residents when it was determined the call light system was not working and needed repairs. The census was 72. 1. Review of Resident #32's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/29/23, showed: -Highly impaired vision; -Cognitively intact; -Required extensive assistance from staff for toilet use and personal hygiene; -Required limited assistance from staff for bed mobility, transfers, dressing, and eating; -Diagnosis included high blood pressure, stroke and dementia. Review of the resident's care plan, undated, showed: Focus: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to post all pertinent State agencies and advocacy groups such as adult protective services and a statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation, including but not limited to resident abuse, neglect, exploitation, and misappropriation of resident property in a form and manner accessible and understandable to residents. The census was 72. Observations throughout the survey from 6/5/23 through 6/8/23, showed staff did not provide any contact information regarding the the State Survey agency. [...]

Inspectors wroteBased on observation and interview, the facility staff failed to ensure they kept the floors clean, kept the areas above the dishwasher clean, and kept the area next to the preparation table in the preparation area clean. The facility census was 77. 1. Observation on 5/13/19 at 11:46 A.M., showed multiple white flakes and various small particles on the floor in the grout area (between the tiles) on the kitchen floor. Observation on 5/17/19 at 10:38 A.M., showed multiple white specks on the kitchen floor by the dishwasher/oven/food prep areas. The particles could be moved with a thumb nail. The flakes stuck to the floor and the grout area had a tacky feel. A clay-like/gummy/oily material, dark in color, which could be removed with a thumbnail lined the black grout of the kitchen floor by the dishwasher/oven/food preparation areas. [...]

Inspectors wroteBased on record review and interview, facility staff failed to conduct and document a thorough facility-wide assessment to determine what resources are necessary to care for residents during both day-to-day operations and emergencies. The facility census was 77. 1. Review of the facility assessment, last updated 4/15/19, showed the intent of the facility assessment is for the facility to evaluate its resident population and identify the resources needed to provide the necessary person-centered care and services the residents require. Review of the facility assessment, showed facility staff involved in completing the assessment included the Administrator, Director of Nursing (DON), and the Regional Nurse Consultant. Review showed the facility did not document the medical director was included in the development and/or review of the facility assessment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to provide care in a dignified manner for five residents (Residents #2, #12, #14, #18, and #37) during the provision of care. The facility census was 77. 1. Review of Resident 37's Minimum Data Set (MDS), a federally mandated assessment tool, dated 3/22/19, showed staff assessed the resident as follows: -Moderate cognitive impairment; -Required extensive assistance from staff with toileting, bed mobility, personal hygiene and dressing; -Required staff supervision and cueing when eating; -Incontinent of bowel and bladder. Observation on 5/16/19 at 5:22 P.M., showed the staff served the resident ham, vegetables, mashed potatoes and apple crisp for dinner in the dining room. Further observation showed two other residents sat at the table assisted by unknown staff. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to maintain a record of personal possessions for two residents (Resident #88 and #96) out of a sample of seven. The facility census was 77. 1. Record review of the facility maintained admission dates for the period 05/01/18 through 05/21/19, showed Resident #88's admission date was 12/05/18. Record review on 05/21/19 of the facility maintained admission file, showed the facility did not complete a personal inventory log of Resident #88's items. During an interview on 05/21/19 at 10:37 A.M., the Business Office Manager said the facility did not keep an inventory for Resident #88. 2. Record review of the facility maintained admission dates for the period 05/01/18 through 05/21/19, showed Resident #96's admission date was 01/22/19. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure residents funds were placed in an account separate from the facility operating account for 21 residents (Resident #7, #13, #17, #35, #38, #45, #51, #55, #58, #89, #94, #101, #103, #111, #112, #113, #114, #115, #116, #117 and #118). Also, the facility failed to use the personal funds of a resident exclusively for the resident and only when authorized in writing for eight residents (Resident #2, #13, #28, #52, #64, #69, #84 and #89) out of a sample of 13. Additionally, the facility failed to obtain authorization to manage personal funds for three residents (Resident #37, #40 and #96) out of a sample of three. The facility census was 77. 1. [...]

Inspectors wroteBased on record review and interview, the facility failed to reconcile resident trust fund accounts monthly. Also, the facility failed to provide a written statement showing the current balance and all transactions to the resident or his/her designee on a quarterly basis. The facility census was 77. 1. Record review of the facility's maintained Resident Trust Fund Account for the period 08/2018 through 05/2019, showed the facility provided bank statements that were not reconciled to the total of resident funds. Record review of the facility's maintained reconciliation attempts to show the total of the resident trust accounts, but there is no documentation to verify the amounts equal. During an interview on 05/21/19 at 3:15 P.M., the Business Office Manager said the reconciliation does not include the step to reconcile the statement with the Resident Trust Fund Ledger total. 2. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide a final accounting of individual resident trust fund balances within 30 days to the individual or probate jurisdiction administering the resident's estate for three residents (Resident #103, #108 and #111) out of a sample of six. Also, the facility failed to provide Medicaid spend down letters when the balance of the resident's trust fund account exceeded $2,800.00 for two residents (Resident #28 and #84) out of a sample of two. The facility census was 77. 1. Record review of the facility maintained Discharge Report for the period [DATE] through [DATE], dated [DATE], showed Resident #108 expired on [DATE]. [...]

Inspectors wroteBased on record review and interview, the facility failed to maintain a surety bond sufficient to ensure protection of resident funds. The facility census was 77. 1. Record review of the facility's attempted Resident Trust Fund Reconciliation for the period 08/2018 through 05/17/19, showed an average monthly balance of $33,127.27. Record review of the facility maintained Accounts Receivable A/R Aging Report for the period 08/01/18 through 05/21/19, dated 05/21/19, showed the facility held an average balance of resident funds in the amount of $20,927.78 in the facility operating account. Record review of the facility's current surety bond showed the facility held a bond in the amount of $50,000.00, which was insufficient by $31,000.00.

Inspectors wroteBased on observation, interview and record review, facility staff failed to provide information to the residents regarding results of the most recent survey of the facility and plan of correction, failed to post accurate notice of the availability of the survey results in an area of the facility that is prominent and accessible to the public, and the failed to make confidential the identifying information about the residents. The facility census was 77. 1. During an interview on 05/15/19 at 11:15 A.M., during the Resident Council Meeting, ten residents and the Activity Director said they have not seen the state survey inspection results available to read for the public and themselves. Review of the State Survey Notebook on 05/15/19 at 5:22 P.M., showed the Resident Identifiers page present with resident names listed. [...]

Inspectors wroteBased on interview and record review, facility staff failed to complete a baseline care plan within 48 hours of admission and failed to document the baseline care plan was reviewed with the resident or responsible party for five residents (Residents #2, #5, #18, #76, and #227) out of 18 sampled residents. The facility census was 77. 1. Review of the facility's Baseline Care Plan policy, dated April 2017, showed facility staff were directed to do the following: -To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within 48 hours of the resident's admission; -The Interdisciplinary team will review the healthcare practitioner's orders and implement a baseline care plan to meet the resident's immediate care needs including, but not limited to: [...]

Inspectors wrote2. Review of Resident #9's significant change MDS, a federally mandated assessment tool, dated 2/7/19, showed staff assessed the resident as: -Cognitively intact; -Required supervision and cueing by staff with eating; -Weight was 181 lbs. Review of the resident's quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Required supervision with eating; -Weight was 164 lbs. Review of the nutrition progress note, dated 3/20/2019, showed the Registered Dietician (RD) assessed the resident's significant weight loss over the last three months. The RD documented that staff should monitor for further weight loss or decreases in the resident's food/fluid intakes. Review of the resident's comprehensive care plan showed staff documented the following interventions for nutrition: -Provide diet education as needed; -Honor food preferences; [...]

Inspectors wroteBased on interview and record review, the facility staff failed to ensure they provided services that meet professional standards when staff failed to aquire a physican's order for a catheter for one resident (Resident #2) and staff did not document that four residents (Residents #2, #5, #17, and #46) received their physican ordered medications in the electronic medication administration records (MAR). This affected four of 18 sampled residents. The facility census was 77. 1. Review of Resident #2's Minimum Data Set (MDS), a federally mandated assessment tool, dated 5/1/19, showed the facility staff assessed the resident as: -Had an indwelling catheter; -Had an ostomy. Review of the resident's comprehensive care plan directed staff on the following interventions for complications related to having a colostomy: -Colostomy care as needed; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed failed to provide activities for daily living when staff failed to provide complete incontinent care every two hours for two residents (Resident #18 and #37), failed to offer fluids to one resident (Resident #37), and failed to reposition three residents (Resident #12, Resident #18, and Resident #37) at least every two hours. This affected three of 18 sampled residents. The facility census was 77. 1. Review of Resident #12's quarterly MDS, dated [DATE], showed staff assessed the resident as: -Mild cognitive impairment for daily decision making; -Has not refused care; -Required extensive assistance on one staff for bed mobility, dressing, eating, and personal hygiene; -Dependent on two or more staff for transferring; -Dependent on one staff toileting; -Limited range of motion to both upper extremities; [...]

Inspectors wroteBased on observation and interview, the facility staff failed to ensure the hot water temperatures did not exceed 120 degrees Fahrenheit (°F) in nine resident rooms (rooms 60, 72, 84, 94, 106, 108, 64, 69, 68, 94, and 108), which 15 residents occupied . The facility census was 77. 1. Observation on 5/13/19, starting at 12:03 P.M., showed: - The hot water temperature in room [ROOM NUMBER] was 123.7 °F. - The hot water temperature in room [ROOM NUMBER] was 128.5 °F; - The hot water temperature in room [ROOM NUMBER] was 128.3 °F; - The hot water temperature in room [ROOM NUMBER] was 127.8 °F; - The hot water temperature in room [ROOM NUMBER] was 125.9 °F; - The hot water temperature in room [ROOM NUMBER] was 126.6 °F; 2. Observation on 5/14/19, starting at 11:17 A.M., showed: - The hot water temperature in room [ROOM NUMBER] was 129.9 °F; [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure nursing staff had the appropriate competencies and skill sets to provide nursing and related services and that nurse aides were trained to care for residents' needs. Staff failed to demonstrate care in a dignified manner for five residents (Resident #2, #12, #14, #18, #37), failed to demonstrate timely incontinence care for two residents (Resident #12, #37) and failed to provide timely repositioning for three residents (Resident #12, #18, #37). Additionally, facility staff failed to offer or encourage fluids for one resident (Resident #37), and failed to demonstrate interventions to prevent significant weight loss for one resident (Resident #12). [...]

Inspectors wroteBased on interview and record, the facility staff failed to ensure one resident who took routine Serequel (an antipsychotic medication) had a Gradual Dose Reduction (GDR) (an attempt to reduce residents off of antipsychotic medications) for one resident (Resident #37) and failed to ensure one resident (Resident #5) who took a PRN (as needed) orders for psychotropic medications were limited to 14 days. This affected two residents (Residents #5 and #37) of 18 sampled residents. The facility census was 77. 1. Review of the facility's Medication Regimen Review (MRR) and Reporting Policy, dated May 2016, showed staff were directed to do the following: -The consultant pharmacist reviews the medication regimen of each resident at least monthly. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure a medication error rate of less than 5 percent (%). Out of 28 opportunities observed, eight errors occurred, resulting in a 28.6% error rate which affected three residents (Residents #19, #46, and #49). The facility census was 77. 1. Review of the facility's Medication Administration General Guidelines Policy, dated May 2016, showed facility staff were directed to do the following: -Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record (MAR) with the medication label. If the label and MAR are different and the container is not flagged indicating a change in directions, or if there is any other reason to question the dosage or directions, the prescriber's orders are checked for the correct dosage schedule; [...]

Inspectors wroteBased on record review and interview, facility licensed staff failed to ensure four residents (Residents #2, #18, #45, #46) were free of significant medication errors when staff did not administer medications to the residents as ordered by the physician. Facility census was 77. 1. Record review of the facility's Medication Administration General Guidelines, dated May 2016, showed staff were directed to do the following: -Medications are administered in accordance with written orders of the prescriber; -The individual who administers the medication dose, records the administration on the resident's Medication Administration Record (MAR) immediately following the medication being given. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications; [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure they followed the recipes and menus planned and approved in advance by the Registered Dietitian (RD). The facility census was 77. 1. Review of the RD approved menu, dated 5/17/19, showed all residents needed to receive: - Baked chicken; - Stuffing with gravy; - Sweet peas & carrots; - English toffee dessert; - Milk; - Beverage. During an interview on 5/17/19 at 10:51 A.M., the DM said the facility currently served 15 residents on a mechanically soft diet and four on a pureed diet. 2. Review of the recipe approved by the RD for pureed vegetables showed: - Vegetables drained and cooked; - Bread slices; - Vegetable juice; - Melted margarine or butter: - Place the vegetables into the food processor. Blend; - Add bread. Blend; - Add a small amount of juice, and blend. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to change gloves and wash hands while providing incontinence care for four residents (Residents #2, #12, #15, and #37). The facility census was 77. 1. Review of the facility's Policy and Procedure Handwashing, dated February 2016, showed staff were directed to perform hand hygiene by washing hands for at least fifteen seconds with antimicrobial (an agent that kills microorganisms) or non-antimicrobial soap and water and should be performed under the following conditions: -When hands are visibly dirty or soiled with blood or other body substances; -Before entering and leaving an isolation room; -Before applying gloves and removing gloves or other Personal Protection Equipment (PPE); -After contact with blood, body fluids, secretions, mucous membranes, or non-intact skin; [...]

Inspectors wroteBased on record review and interview, facility staff failed to report an allegation of abuse to the State Survey Agency, for one (Resident #60) of 18 sampled residents. The facility census was 77. Review of the facility's Policy & Procedure Abuse and Neglect Prevention, dated revision February 2017, showed: -To establish guidelines that prevents, identifies, and reports resident abuse and neglect; -All residents have the right to be free from abuse/neglect; -It shall be the policy of this facility to implement written procedures that prohibit abuse/neglect; -These procedures shall include timely reporting of abuse/neglect; -Reporting: [...]

Inspectors wroteBased on observation, interview, and record review the facility staff failed to provide treatments as order by the physician for two residents (Resident #5 and # 46) with vascular wounds. The facility census was 77. 1. Review of Resident #5's Minimum Data Set (MDS), a federally mandated assessment tool, dated 12/8/18, showed staff assessed the resident as: -admission date of 12/1/2018; -No cognitive impairment; -Required extensive assistance of one staff for bed mobility, transfers, dressing, toileting, and personal hygiene; -Occasionally incontinent of bowel and bladder; -Occasional pain; -Had falls in the last six months prior to admission; -A risk for pressure ulcers; -Received antipsychotics six out of seven days, antidepressants seven out of seven days, opioids four out of seven days, during the last seven days or since admission/entry if less than seven days. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one resident (Resident #2) out of four residents with pressure ulcers received the treatment as ordered by the physician and failed to provide the pressure ulcer documentation required in the weekly wound report. The census was 77. 1. Review of Resident #2's Minimum Data Set (MDS), a federally mandated assessment tool, dated 5/1/19, showed staff assessed the resident as: -Moderate cognitive impairment; -Required extensive assistance from staff with toileting, personal hygiene and bed mobility; -One sided weakness; -Received more than 51% of nutrition by a feeding tube; -Mechanically altered diet; -Indwelling catheter; -Ostomy; -At risk for the development of a pressure ulcer; [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one (Resident #14) of 18 sampled residents. The facility census was 77. 1. Review of Resident #14's significant change Minimum Data Set (MDS), a federally mandated assessment tool, dated 2/18/19, showed staff assessed the resident as the following: -Highly impaired hearing/no hearing aid; -No speech; -Rarely/never understood; -Rarely/never understands; -Highly impaired vision/no corrective lenses; -Severely impaired cognitive skills for daily decision making; -Has not refused care; -Dressing: extensive assistance/one person physical assist; -Upper extremity/lower extremity: both had impairment on one side; -Diagnosis: [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure acceptable parameters for nutritional status were maintained, failed to provide assistance with eating to prevent significant weight loss, and failed to notify the Physician and resident representative of the significant weight loss for one resident (Resident #12) of five residents reviewed for nutrition in a sample of 18 residents. The facility census was 77. 1. Review of the facility's Weight and Hydration Management Overview Practice Guidelines Policy, dated February 2016, directed staff to do the following: -Registered Dietician will complete Nutrition Risk Assessment on admission and the dietary manager will complete the dietary profile; -Nurses will assess resident oral status and nutrition status on admission assessment; [...]

Inspectors wroteBased on observation and interview, the facility staff failed to ensure they made the pureed food timely to prevent a skim from forming and to ensure the pureed food had a smooth consistency free of chunks. The facility census was 77. 1. During an interview on 5/17/19 at 10:51 A.M., the Dietary Manager (DM) said the kitchen staff had already pureed most of the foods and they placed the pureed foods into the steamer. They typically completed their purees around 10:00-10:15 A.M. and kept them in the steamer until they are served at the 12:00 noon meal times. Observation on 5/17/19 at 12:43 P.M. showed a three inch by three inch skim had formed over the pureed chicken. [NAME] A served out the pureed foods while the skim was formed over the top of the pureed chicken. During an interview on 5/17/19 at 1:11 P.M., the DM said he had been trained to puree foods far in advance of the meals. [...]