Fulton Manor Care Center

Inspectors wroteBased on interview and record review, facility staff failed to issue an appropriate emergency discharge notice for one resident (Resident #1) when the emergency discharge notice did not contain a location and failed to notify the Ombudsman of the emergency discharge to the hospital and refused to allow him/her to return to the facility when discharged from the hospital. The facility census was 48. 1. Review of the facility's Transfer or Discharge Emergency policy, dated 08/18, showed it did not direct staff in regard to appropriate discharge location, or in regards to contact information for the Ombudsman noted on the discharge to allow for an appeal when issuing an emergency transfer or discharge notice. 2. Review of Resident #1's face sheet, dated 6/15/26, showed the resident admitted to the facility on [DATE] and staff discharged him/her to the local hospital on 5/18/26. [...]

Inspectors wroteBased on record review and interview, facility staff failed to complete a Criminal Background Check (CBC) for three employees (Certified Nurse Assistant (CNA) A, CNA B, and CNA C), out of three sampled employees, as required by the Missouri Department of Health and Senior Services (DHSS) and facility policy. The facility's census was 45.1. Review of the facility's Abuse, Neglect and Exploitation policy, dated 01/31/24, showed potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. The facility will maintain documentation of proof that the screening occurred. [...]

Inspectors wroteBased on interviews and record review, facility staff failed to ensure one resident (Resident #1) remained free physical abuse, when Certified Nursing Assistant (CNA) B witnessed CNA A tie a sheet around the resident's upper body to restrain the resident to his/her wheelchair as a form of discipline to control the resident's behavior. The facility's census was 45. The administrator was notified on 04/27/26 of Past Non-Compliance which occurred on 04/16/26, when staff reported CNA A restrained the resident with a sheet to his/her wheelchair. On 04/16/26, staff assessed the resident for physical and psychological harm, the administrator investigated the allegation, notified the required parties and agencies, re-educated staff on the facility's abuse and neglect policy, and immediately terminated CNA A. 1. [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure the facility did not employ or engage staff who had a Federal Indicator (a marker given by the federal government to individuals who have committed abuse, neglect, or misappropriation of property) on the Certified Nurse Aide (CNA) Registry for one employee (CNA A) out of four sampled employees. The facility census was 45. 1. Review of the facility's policy, Abuse, Neglect and Exploitation Policy, dated 01/31/24, showed it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriation of resident property; -Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide reasonable accommodations to meet the needs of the residents, when staff failed to ensure call lights were placed within reach for four residents (Resident #4, #10, #48, and #295) out of 16 sampled residents. The facility's census was 43. 1. Review of the facility's policy titled, Call Lights: Accessibility and Timely Response, dated 01/01/25, showed the purpose of the policy is to assure the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance, and directed staff: -All staff will be educated on the proper use of the resident's call system, including how the system works and ensuring resident access to the call light; -All residents will be educated on how to call for help using the resident call system; [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide written notification information to the resident and/or the resident's representative of the bed hold policy at the time of transfer to the hospital, or therapeutic leave for four (Resident #3, #14, #20, and #26) out of four sampled residents. The facility's census was 43. 1. Review of the facility's policies showed the facility did not provide a policy for Bed Hold. 2. Review of Resident #3's medical record showed: -discharged from the facility on 11/19/24 and readmitted to the facility on [DATE]; -Did not contain written documentation staff notified the resident or the resident's responsible party of the facility's bed-hold policy. 3. Review of Resident #14's medical record showed: -discharged from the facility on 12/31/24 and readmitted to the facility on [DATE]; [...]

Inspectors wroteBased on interviews and record review, facility staff failed to complete a baseline care plan within 48 hours of admission for five residents (Resident #20, #43, #45, #46, and #48) out of 16 sampled residents. The facility census was 43. 1. Review of the facility's policy titled, Care Plans-Baseline', dated December 2016, showed a baseline plan of care to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission. 2. Review of Resident #20's electronic medical record (EMR), showed staff documented the resident admitted to the facility on [DATE]. The EMR did not contain documentation staff completed a baseline care plan within 48 hours of admission. 3. Review of Resident #43's EMR, showed staff documented the resident admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to follow professional standards of practice when staff failed to obtain physician's orders for water flushes/flush medications with water per facility policy, failed to administer medications as directed by the physician and the medication administration record (MAR), and failed to ensure a licensed staff member documented medication administration via Gastric Tube (G-Tube), a surgically inserted tube which provides nutrition, hydration, or medicine directly into the stomach, for one resident (Resident #20) of one sampled resident. Licensed staff failed to perform colostomy (an opening in the abdomen to the intestines) care as directed by the physician for one resident (Resident #48) of one sampled resident. The facility census was 43. 1. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide care to meet basic hygiene needs for four residents (Resident #24, #32, #35, and #48) out of six sampled residents. The facility census was 43. 1. Review of the facility's, Bath, Shower/Tub Policy, dated February 2018, showed staff are directed: -The purpose of this procedure is to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin; -Document the date and time the shower/bath was performed; -If the resident refused the shower/tub bath, the reason(s) why and the intervention taken; -Notify the supervisor if the resident refuses the shower/tub bath. 2. Review of Resident #24's Quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 10/17/24, showed staff assessed the resident as follows: -Mild cognitive impairment; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to obtain signed consents for side rails and failed to complete side rail assessments for four residents (Resident #3, #15, #20 and #46), out of four sampled residents. The facility census was 43. 1. Review of the facility's Proper use of Side Rails Policy, undated, showed: -Examples of bedrails include, but are not limited to side rails, bed side rails, safety rails, grab bars, and assist bars; -The resident assessment must assess the resident's risk from using bed rails such as entrapment; -The resident assessment should assess the resident's risk of entrapment between the mattress and bed rail or in the bed rail itself; -Informed consent from the resident or resident representative must be obtained after appropriate alternative have been attempted prior to installation and use of bed rails; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide staff in accordance with their Facility Assessment to meet the needs of the residents. Staff failed to provide care to meet basic hygiene needs for four residents (Resident #24, #32, #35, and #48) out of six sampled residents. The facility census was 43. 1. Review of the Facility Assessment, dated 01/07/25, showed direct care staff required to care for their facility census: -Days- Five nurse aides with census above 43 or three-four nurse aides with census lower than 40; -Evenings- Four nurse aides with census above 43 or two-three nurse aides with census below 40; -Nights- Two nurse aides; -Staffing plan is to ensure that facility has sufficient staff to meet the needs of the residents at any given time. Review of the employee schedule, dated August 2024, with average census of 42, showed: [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide the services of a Registered Nurse (RN), for at least eight consecutive hours per day, seven days a week. The facility census was 43. 1. Review of the facility's policy titled, Nursing Services-Registered Nurse (RN), dated 01/01/24, showed the facility will utilize the services of a Registered Nurse for at least eight consecutive hours per day, seven days per week. 2. Review of the facility's RN staff schedule, dated July 2024, showed the facility did not have an RN, eight consecutive hours a day, in the building for the dates of: -Monday, 07/01/24; -Tuesday, 07/02/24; -Wednesday, 07/03/24; -Thursday, 07/04/24; -Monday, 07/08/24; -Tuesday, 07/09/24; -Wednesday, 07/10/24; -Thursday, 07/11/24; -Friday, 07/12/24; -Saturday, 07/13/24; -Sunday, 07/14/24; -Monday, 07/15/24; -Tuesday, 07/16/24; -Wednesday, 07/17/24; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to complete the required nurse staffing information, which included the facility census, the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, per shift, on a daily basis in an area readily accessible to residents and visitors. The facility census was 43. 1. Review of the facility's policy titled, Posting Direct Care Daily Staffing Numbers, dated 07/2016, showed: -Within two hours of the beginning of each shift, the number of licensed nurses and the number of unlicensed nursing personnel directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) in a clear and readable format; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure a medication error rate of less than five percent (5%). Out of 32 opportunities observed, nine errors occurred, resulting in a 28.13% error rate, which affected one resident (Resident #20) out of four sampled residents. The facility's census was 43. 1. Review of the facility's policy titled, Medication Errors, dated 01/01/24, showed the facility must ensure that it is free of medication error rates of 5% or greater. Review of the facility's policy titled, Administering Medications, dated April 2019, showed: -Medications are administered in a safe and timely manner, and as prescribed; -Medications are administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders); [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to ensure the dish washing machine operated according to manufacturer's instructions in a manner adequate to prevent cross contamination of kitchen wares. Facility staff failed to properly sanitize soiled kitchen wares to prevent cross-contamination. Facility staff failed to maintain an ice machine drain air gap. The facility census was 43. 1. Review of the facility's Dishwashing: Machine Operation policy, dated 2020, showed staff were instructed to: -Operate dishwashing machines according to manufacturer recommendations; -Record log documents twice daily for either final rinse temperature (high temperature machine) or sanitizer concentration (low temperature machine with chemical sanitizer); [...]

Inspectors wroteBased on interview and record review, the facility staff failed to develop and implement an effective Quality Assurance (QA)/Quality Assurance Performance Improvement (QAPI) program which included documentation and implementation of on-going systemic issues with resolution. The facility census was 43. 1. Review of the facility's policies showed the facility did not provide a policy for QA/QAPI program. During an interview on 01/30/25 at 10:23 A.M., the administrator said the department heads come together quarterly and discuss different items within the facility, however there is no documentation to provide about these meetings or issues and resolutions. The administrator said she was not aware the information needed to be documented and maintained.

Inspectors wroteBased on observation, interview and record review, facility staff failed to ensure the two-step purified protein derivative ((PPD) skin test for Tuberculosis (TB)) were completed in accordance with their policy for six employees (Licensed Practical Nurse (LPN) A, Nurse Aide (NA) B, NA C, NA D, Certified Nurse Aide (CNA) E, and Dietary aide F) out of ten employee files reviewed. Facility staff failed to implement the Enhanced Barrier Precautions (EBP) policy when they did not educate, or alert staff of residents who required EBP, and failed to place appropriate personal protective equipment (PPE) in close proximity for three residents (Resident #20, #45, and #48) of three sampled residents. The facility's cenus was 43. 1. Review of the Facility's Employee Screening for TB, revised August 2019, showed: [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to complete regular inspections of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for four residents (Residents #3, #15, #20, and #46) out of four sampled residents. The facility census was 43. 1. Review of the facility's policies showed staff did not provide a policy for Entrapment Risk Assessments. Review of the facility's policy titled, Proper Use of Side Rails, undated, showed the facility will assure the correct installation and maintenance of bed rails prior to use ensuring that the beds dimensions are appropriate for the resident by: -Confirming the bed rails are appropriate for the size and weight of the resident using the bed; -Inspecting and regularly checking the mattress and bed rails for ares of possible entrapment; [...]

Inspectors wroteBased on observation and interview, facility staff failed to ensure residents' personal information and privacy was protected when staff left the computer screen open in public hallways for two residents (Resident #9 and #13) of 16 sampled residents, and failed to close the privacy curtain and window blinds/curtain during incontinence care for one resident (Resident #48) out of two sampled residents observed during care. The facility's census was 43. 1. Review of the facility's policy titled, Quality of Life-Dignity, dated 01/01/24, showed: -Each resident shall be cared for in a manner that promotes and enhances his/her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem; -Staff protect confidential clinical information; [...]

Inspectors wroteBased on interview and record review, facility staff failed to complete the required Minimum Data Set (MDS), a federally mandated resident assessment, within the required time frame for three residents (Residents #20, #24 and #48) of six sampled residents. The facility's census was 43. 1. Review of the facility's policy titled, MDS Completion and Submission Timeframes, dated July 2017, showed staff are directed: -The Assessment Coordinator or designee is responsible for ensuring the resident assessments are submitted to Centers for Medicare and Medicaid Services (CMS) Quality Improvement and Evaluation Service (QIES) Assessment Submission and Processing (ASAP) system in accordance with the current federal and state guidelines; -Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument (RAI) Manual; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to develop a comprehensive person-centered care plan to meet the resident's medical, nursing, mental and psychosocial needs for three residents (Resident #1, #15, and #16) out of 16 sampled residents. The facility's census was 43. 1. Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated 01/01/24, showed: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; -The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment; -The comprehensive, person-centered care plan is developed within seven days of the completion of the required comprehensive assessment; [...]

Inspectors wroteBased on interview and record review, facility staff failed to implement an Antibiotic Stewardship Program with antibiotic use protocols and a system to monitor and track antibiotic use within the facility. The facility census was 43. 1. Review of the facility's policies showed the facility did not provide a policy for Antibiotic Stewardship. Review of the facility's antibiotic stewardship program showed facility staff did not have a process in place to track and trend antibiotic usage. During an interview on 01/28/25 at 8:30 A.M., the Director of Nursing (DON) said he has the Infection Preventionist but has only been employed at the facility for eight days. He said he is unsure what was being done before he came, but unfortunately he does not have an antibiotic stewardship program to provide. [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure one resident (Resident #1) remained free from physical abuse when Resident #2 who had a history of physical aggression grabbed Resident #1's arm. The facility census was 39. 1. Review of the facility's Abuse, Neglect, and Exploitation Policy, dated 1/31/24, showed abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish which can include staff to resident abuse and certain resident to resident altercations. Review showed physical abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. 2. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment tool used to plan care, dated 9/08/24, showed staff assessed the resident with cognitive impairment. [...]

Inspectors wroteBased on observation, record review, and interview, facility staff failed to prevent the misappropriation of money from one resident's (Resident #1's) checking account when Certified Nurse Assistant (CNA) I cashed a check from the resident for his/her personal use. The facility census was 43. The administrator was notified on 8/12/24 of past Non-Compliance which occurred on 6/22/24. On 7/27/24, facility staff reported CNA I received, accepted, and cashed a check in the amount of $400.00 from a resident on 6/22/24. Upon discovery 7/27/24, facility staff began an investigation. Facility staff notified the Department of Health and Senior Services (DHSS), local police department, and the residents physician. Facility staff completed an investgation and all staff inserviced on abuse, neglect, and misappropriation by 7/30/24. CNA I terminated on 7/27/24 for misappropriation of resident money. [...]

Inspectors wroteBased on interview and record review, staff failed to implement the facility's abuse policy to ensure resident safety when facility staff allowed Physical Therapy Assistant (PTA) A who was accused of abuse of one resident (Resident #1) out of three sampled residents to continue to have contact with residents. The facility census was 36. 1. Review of the facility's Abuse Prevention Policy, dated November, 2017, showed each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Resident who reside in our facilities will not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate qualifications, when the facility did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. The census was 37. 1. Review of facility provided policies showed they did not contain a policy related to the qualifications of kitchen staff. Review of facility provided e-mails showed the consultant dietician requested the current Dietary Supervisor's enrollment in the on-line Certified Dietary Manager's (CDM) course on 08/29/23. Review showed the consultant dietician provided the administrator with the Dietary Supervisor's login information for the on-line CDM course on 08/31/23. During an interview on 02/06/24 at 9:55 A.M., the Dietary Supervisor (DS) said he/she was not a CDM. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to serve food in accordance with the nutritionally calculated menus and standardized recipes. Facility staff failed to inform residents what meals were being served and when changes were made to the menus. The census was 37. 1. Review of the facility's Pureed Diet policy, dated 2022, showed staff were directed to weigh or measure the number of drained portions required for the standardized recipe. Review showed the policy directed staff to serve with appropriate scoop number or divide equally to provide number of portions. Review of the facility's Mechanical Soft Diet policy, dated 2022, showed the policy did not contain direction related to portion sizes. Review of the standardized recipe for ground ham steak with gravy showed staff are instructed to place prepared ham in a washed and sanitized food processor; [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to maintain kitchen cleanliness in a manner to prevent potential food contamination. Facility staff failed to store food in a manner to prevent potential contamination and outdated use. Facility staff failed to maintain and serve food at temperatures adequate to prevent food borne illness. Facility staff failed to sanitize kitchen wares in a manner to prevent contamination, and to store dish wares in a manner to prevent cross-contamination when staff stacked dish wares together wet. The facility census was 37. 1. Review of the policies provided by the facility showed the policies did not contain guidance related to kitchen cleaning. Review of the facility's Ice Machines and Portable Ice Carts policy, dated 2024, showed: [...]

Inspectors wroteBased on observation, record review, and interview, facility staff failed to appropriately perform hand hygiene during wound care, perineal care and catheter care for one resident (Resident #30), failed to perform hand hygiene during perineal care for one resident (Resident #16), failed to perform hand hygiene between residents during medication administration, and failed to change and store oxygen tubing in a manner to decrease the risk of the spread of infection for four residents (Resident #3, #11, #23, and #142). The facility census was 37. 1. Review of the facility's Hand Hygiene policy, reviewed January 2024,showed: -Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice; [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide refunds of personal funds to residents from the facility operating account in a timely manner for nine residents (Resident #1, #5, #7, #8, #10, #12, #14, #15, and #17) discharged from the facility. The facility census was 37. 1. Review of the Facility's Resident Personal Fund policy, dated January 2024, showed: -The facility will establish and maintain a system that assures a full and complete and separate accounting of each resident's personal funds entrusted to the facility on the resident's behalf. The system will preclude any comingling of resident funds with facility funds; [...]

Inspectors wroteBased on record review, observation and interview, facility staff failed to provide a comfortable and homelike environment for residents, when failed to repair a door covering, stored a bed side commode lid on the floor next to the sink and stored a wash basin on the floor in the bathroom by the toilet in room [ROOM NUMBER]. Staff failed to maintain and clean the portable ice chest and failed to maintain the front entranceway free of cigarette butts. The facility census was 37. 1. Review of the facility's Safe and Homelike policy, reviewed January 2024, showed: -The facility will create and maintain, to the extent possible, a homelike environment that deemphasized the institutional character of the setting; -Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to follow physician orders for one resident's (Resident #25) indwelling urinary catheter (tube inserted into the bladder to drain urine) care and failed to obtain a physician's order for an indwelling urinary catheter which included an indication for the use, catheter care, and catheter/balloon size for one resident (Resident #30). The facility census was 37. 1. Review of the facility's Appropriate Use of Indwelling Catheters policy, reviewed January 2024 showed the following: -An indwelling catheter will be utilized only when a resident's clinical condition demonstrates that catheterization was necessary; -Residents admitted with an indwelling catheter, will be assessed for removal of the catheter as soon as possible unless the clinical condition demonstrates that catheterization is necessary; [...]

Inspectors wroteBased on observations, interview, and record review, facility staff failed to assist five residents (Resident #3, #11. #18, #38, and #142) out of 12 sampled dependent residents with grooming and bathing. The facility census was 37. 1. Review of the facility's Activities of Daily Living (ADLs), Supporting, dated March 2018, showed staff were directed as follows: -Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLS); -Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to propel four residents (Resident #11, #13, #18 and #43) in wheelchairs with foot pedals, failed to provide a safe mechanical lift transfers for two residents (Residents #16 and #22), and failed to secure chemicals and disposable razors in a manner to prevent accidents. The facility census was 37. 1. Review of the facility's No Pedals, No Push policy, dated June 2013, showed: -Staff will be aware to place foot pedals on wheelchairs if staff is going to push a resident to prevent a resident from having to hold up his/her own legs potentially causing a resident to drop their legs and throwing them out of the wheelchair; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to obtain a physician's order for an indwelling urinary catheter (tube inserted into the bladder to drain urine) which included an indication for the use, catheter care, and catheter/balloon size for one resident (Resident #30), failed to obtain an updated physician order and administer catheter care for one resident (Resident #25). The facility census was 37. 1. Review of the facility's Appropriate Use of Indwelling Catheters policy, reviewed January 2024, showed an indwelling catheter will be utilized only when a resident's clinical condition demonstrates that catheterization was necessary. Review showed: -Residents admitted with an indwelling catheter, will be assessed for removal of the catheter as soon as possible unless the clinical condition demonstrates that catheterization is necessary; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to accurately complete entrapment assessments, bedrail assessments, and obtain consents for the use of bed rails for four residents (Resident #6, #16, #32, and #142). The facility census was 37. 1. Review of the facility's Bed Safety and Bed Rails policy, dated August 2022, showed: -Bed frames, mattresses and bed rails are checked for compatibility and size prior to use; -Bed dimensions are appropriate for the resident's size; -Regardless of mattress type, width, length, and/or depth, the bed frame, bed rail and mattress will leave not gap wide enough to entrap a resident's head or body. Any gaps in bed system are within the safety dimensions established by Food and Drug Administration (FDA); [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing staff had the appropriate skills and competencies to meet the care needs for the residents by not providing in-services or reevaluating and documenting skills and competencies on a regular basis for each employee. The facility census was 37 residents. 1. Review of the facility's Competency Evaluation policy, updated [DATE] showed it is the policy of this facility to evaluate each employee to assure appropriate competencies and skills for performing his or her job and to meet the needs of facility residents. Review showed: -The knowledge and skills required among staff to meet residents' needs are determined through the facility assessment process; -Evaluating competency of staff is accomplished through the facility's training program; -Initial competency is evaluated during the orientation process. [...]

Inspectors wroteBased on interview and record review, facility staff failed to implement an Antibiotic Stewardship Program with a system to monitor antibiotic use. The facility census was 37. 1. Review of the facility's Antibiotic Stewardship policy, reviewed January 2024, showed the purpose of the Antibiotic Stewardship program is to monitor the use of antibiotics in our residents. If an antibiotic is indicated, prescribers will provide complete antibiotic orders including the following elements: -Drug name; -Dose; -Frequency of administration; -Duration of treatment (start and stop date) or (number of days of therapy); -Route of administration; -Indication of use. Review of the facility's Infection Prevention and Control policy, reviewed May 2023, showed: -An antibiotic stewardship program will be implemented part of the overall infection prevention and control program; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to develop and implement a comprehensive person-centered care plan for two residents (Resident #6, and #29). The facility census was 37. 1. Review of the facility's Care Plans, Comprehensive Person-Centered policy, reviewed January 2024 showed: -The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident; -The interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment; -The comprehensive, person-centered care plan will include measurable objectives and timeframes; incorporate identified problem areas; incorporate risk factors associated with identified problems; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to update care plans with intervention for pressure ulcers, and complete weekly skin assessments after development of pressure ulcer for two residents (Resident #29 and #30). Facility staff failed to notify one resident (Resident #29) physician and family of new pressure ulcers and failed to recieve an treatment order and an order for wound care consult. Facility staff failed to initiate a wound care consult and did not document they provided physician order treatments for one resident (Resident #30). The facility census was 37. 1. Review of the facility's Prevention of Pressure Injuries policy, dated April 2020, showed staff are directed to: -Assess the resident on admission for existing pressure injury risk factors. Repeat weekly and upon any changes in condition. [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure as needed psychotropic medication orders were limited to 14 days unless specific duration and clinical rationale were provided for one resident (Resident #25). The facility census was 37. 1. Review of the facility's Gradual Dose Reduction of Psychotropic Drugs policy, reviewed 01/01/24, showed residents who use psychotropic drugs receive gradual dose reduction and behavioral interventions, unless clinically contraindicated, in an effort to discontinue those drugs. The policy did not give direction for responses to GDR recommendations from the pharmacist or physician or for 14-day as needed psychotropic medications. Review of the facility's Medication Administration policy, reviewed 01/01/24, showed the following: -Medications are administered in accordance with prescriber orders, including any required time frame. [...]

Inspectors wroteBased on observation, interviews, and record review, facility staff failed to store medication in a safe and effective manner. The facility census was 37. 1. Review of the facility's Storage of Medications policy, dated 01/01/24, showed facility staff were directed as follows: -The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner; -Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing; -Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. 2. Observation on 02/08/24 at 01:25 P.M., showed the medication storage room contained: [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure the most recent survey results were posted and readily accessible to residents, family member or representatives of residents. The facility census was 37. 1. Review of the facility's Availability of Survey Results Policy, reviewed January 2024, showed: -A readable copy of our facility's most recent federal and/or state survey report and plan of correction for any identified deficiencies is maintained in a 3-ring loose-leaf binder titled Results of Most Recent Survey; -The Survey binder is located in the main lobby and is available for review by interested persons who wish to review information relative to our facility's compliance with federal and state rules, regulations, and guidelines governing our facility's operation; [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide residents with a written response to grievances. The facility census was 37. 1. Review of the facility's Resident and Family Grievances policy, dated 01/01/24, showed staff were directed as follows. -The grievance officer is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the residents; and coordinating with state and federal agencies as necessary in light of specific allegations; -Upon request, the facility will give a copy of this grievance policy of the resident; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to post the required nurse staffing information, which included the resident census, and 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 in an area readily accessible to residents and visitors. The facility failed to maintain the posted nursing staff data for 18 months. The facility census was 37. 1. Review of the facility's Posting Direct Care Daily Staffing Numbers, reviewed 1/1/24, showed: -Within two (2) hours of the beginning of each shift, the number of Licensed Nurses: [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to maintain kitchen equipment in a clean and sanitary manner and to perform hand hygiene as often as necessary to prevent cross-contamination. This failure had the potential to affect all residents. The census was 32. 1. Review of the facility's Dietary Cleaning and Sanitation policy, undated, showed: - The floors shall be swept and mopped prior to the end of each shift; - The floors shall be swept and mopped if they become dirty; - Ovens need to be cleaned on a regular basis and whenever they are soiled; - Cabinets and drawers should be cleaned on a regular basis and whenever they are soiled. Review of the facility's Daily Checklist for cleaning, undated, showed: - The dietary aid to wipe down wall tiles of any visible splashes, wipe down trash cans, and sweep and mop the dishwashing area; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure razors/sharps and hazardous chemicals were stored in safe manner not accessible to residents when staff failed to lock an unattended medication storage room and unlocked medication cart and failed to provide safe mechanical lift transfers for two residents (Residents #20 and #30) in a manner to prevent accidents. The facility census was 32. 1. Review of the facility's Safety and Supervision of Residents policy, dated July 2017 showed: -Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents; -The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. 2. [...]

Inspectors wroteBased on interview and record review, facility staff failed to develop a comprehensive care plan for two residents (Resident #6 and #15) of six sampled residents. The facility census was 32. 1. Review of the facility's Care Plans, Comprehensive Person-Centered policy dated March 2022 showed the comprehensive, person-centered care plan is developed within seven days of the completion of the required MDS assessment, and no more than 21 days after admission. 2. Review of Resident #6's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/16/22, showed staff assessed the resident as follows: -Severe cognitive impairment; -Moderate depression; -Physical behaviors directed toward others on 1-3 days; -Behaviors significantly interfere with the resident's care; -Total dependence for bed mobility, transfer, dressing, locomotion, eating, toilet use, and personal hygiene; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to obtain a physician order for the use of oxygen for one resident (Resident #27). The facility census was 32. 1. Review of the facility's Medication and Treatment Orders policy, revised July 2016, showed: -Medication shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state; -Drug and biological orders must be recorded on the Physician's Order Sheet in the resident's chart. Review of policies provided by the facility showed they did not provide a policy specific to oxygen administration. Review of Resident #27's quarterly Minimum Data Set (MDS), a federally mandated resident assessment tool, dated 11/17/22, showed facility staff assessed the resident as follows: -Diagnoses included asthma; [...]

Inspectors wroteBased on observation, interviews, and record reviews, facility staff failed to prepare pureed food according to recipes, to ensure residents with pureed diets received all items on the menu, and to serve pureed food at the appropriate consistency. This failure had the potential to affect two out of two residents (Resident #16 and #19) who received a pureed diet. The census was 32. 1. Review of the facility's Standardized Recipes policy, undated, showed standardized recipes will be used for all menu items, including pureed and therapeutic diets. Review of the diet spreadsheet for residents with pureed diets showed, staff directed to prepare pureed beef cube steak, pureed creamed corn, pureed stewed tomatoes, pureed buttered dinner roll, and pureed bread pudding for the resident's lunch meal. Review of the pureed bread pudding recipe showed, staff directed to: [...]